Provider Demographics
NPI:1619918554
Name:BANIK, UTTAM K (PA-C)
Entity Type:Individual
Prefix:
First Name:UTTAM
Middle Name:K
Last Name:BANIK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1208
Mailing Address - Country:US
Mailing Address - Phone:860-714-4088
Mailing Address - Fax:860-714-8263
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4088
Practice Address - Fax:860-714-8263
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010020363A00000X
CT001766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant