Provider Demographics
NPI:1790753929
Name:BANNING, MICHELLE JEAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEAN
Last Name:BANNING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 DAN ARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72833-0220
Mailing Address - Country:US
Mailing Address - Phone:479-495-7300
Mailing Address - Fax:479-495-7891
Practice Address - Street 1:804 DAN ARK CIRCLE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-0220
Practice Address - Country:US
Practice Address - Phone:479-495-7300
Practice Address - Fax:479-495-7891
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135336001Medicaid
CS8405OtherRAILROAD MEDICARE
AR135336001Medicaid
AR5K939Medicare ID - Type Unspecified