Provider Demographics
NPI:1639139470
Name:BANIGO, DIANE RENEE (CNM)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RENEE
Last Name:BANIGO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:ISAAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3033 EXCELSIOR BLVD STE 585
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-6400
Mailing Address - Country:US
Mailing Address - Phone:612-345-5920
Mailing Address - Fax:844-562-6828
Practice Address - Street 1:3033 EXCELSIOR BLVD STE 585
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-6400
Practice Address - Country:US
Practice Address - Phone:612-345-5920
Practice Address - Fax:844-562-6828
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152803-1367A00000X
MNR152803-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN088H5BAOtherBCBS
MNHP58089OtherHEALTH PARTNERS
MN07-04617OtherMEDICA
MN238495700Medicaid
MN923911045942OtherPREFERRED ONE
MN182098OtherUCARE
MNQ61557Medicare UPIN
MNQ6157Medicare UPIN
MN07-04617OtherMEDICA
MN182098OtherUCARE