Provider Demographics
NPI:1609418342
Name:BANKSTON, JOSHUA WAYNE
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:WAYNE
Last Name:BANKSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 BLUE WATER POINTE DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35504-4075
Mailing Address - Country:US
Mailing Address - Phone:205-387-4148
Mailing Address - Fax:
Practice Address - Street 1:809 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2029
Practice Address - Country:US
Practice Address - Phone:205-759-7122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-159330363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL224805Medicaid