Provider Demographics
NPI:1639443880
Name:BANKS, MATTHEW CHAD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:CHAD
Last Name:BANKS
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:PO BOX 980
Mailing Address - Street 2:
Mailing Address - City:CHALLIS
Mailing Address - State:ID
Mailing Address - Zip Code:83226-0980
Mailing Address - Country:US
Mailing Address - Phone:208-879-4351
Mailing Address - Fax:208-879-5216
Practice Address - Street 1:611 CLINIC RD
Practice Address - Street 2:
Practice Address - City:CHALLIS
Practice Address - State:ID
Practice Address - Zip Code:83226
Practice Address - Country:US
Practice Address - Phone:208-879-4351
Practice Address - Fax:208-879-5216
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA0235363AM0700X
IDPA1377363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical