Provider Demographics
NPI:1629691811
Name:BANTA, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BANTA
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 1:436 FRIENDLY HILL RD
Mailing Address - Street 2:
Mailing Address - City:FRIENDLY
Mailing Address - State:WV
Mailing Address - Zip Code:26146-7400
Mailing Address - Country:US
Mailing Address - Phone:304-312-6940
Mailing Address - Fax:
Practice Address - Street 1:436 FRIENDLY HILL RD
Practice Address - Street 2:
Practice Address - City:FRIENDLY
Practice Address - State:WV
Practice Address - Zip Code:26146-7400
Practice Address - Country:US
Practice Address - Phone:304-312-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant