Provider Demographics
NPI:1639477094
Name:BANKS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BANKS
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 1:1927 IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2563
Mailing Address - Country:US
Mailing Address - Phone:208-746-8547
Mailing Address - Fax:
Practice Address - Street 1:1927 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2563
Practice Address - Country:US
Practice Address - Phone:208-746-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA1967237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter