Provider Demographics
NPI:1639424146
Name:BANCHEK, BENJAMIN DAVID (FNP)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DAVID
Last Name:BANCHEK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 STUART STREET, ROOM(S) #1-56 & 1-56A
Mailing Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL ATM: MCXL-PQ (CREDENTI
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5720
Mailing Address - Country:US
Mailing Address - Phone:803-751-2789
Mailing Address - Fax:
Practice Address - Street 1:4500 STUART STREET, ROOM(S) #1-56 & 1-56A
Practice Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL ATM: MCXL-PQ (CREDENTI
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-5720
Practice Address - Country:US
Practice Address - Phone:803-751-2789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO160115363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily