Provider Demographics
NPI:1891860086
Name:BANAS, SANDRA MARIE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARIE
Last Name:BANAS
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 1:8100 OSWEGO ROAD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-652-6551
Mailing Address - Fax:315-652-9698
Practice Address - Street 1:8100 OSWEGO ROAD
Practice Address - Street 2:SUITE 220
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-652-6551
Practice Address - Fax:315-652-9698
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
386878OtherMVP HEALTHCARE INSURER
H84723Medicare UPIN