Provider Demographics
NPI:1821163734
Name:BANKS, SUSAN M
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:BANKS
Suffix:
Gender:F
Credentials:
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 2431
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:AK
Mailing Address - Zip Code:99574-2431
Mailing Address - Country:US
Mailing Address - Phone:907-424-7792
Mailing Address - Fax:907-424-7936
Practice Address - Street 1:1400 COOPER RIVER HIGHWAY
Practice Address - Street 2:#1
Practice Address - City:CORDOVA
Practice Address - State:AK
Practice Address - Zip Code:99574-2431
Practice Address - Country:US
Practice Address - Phone:907-424-4935
Practice Address - Fax:907-424-7936
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM3359Medicaid