Provider Demographics
NPI:1912568627
Name:BANIEL, MARY KATE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATE
Last Name:BANIEL
Suffix:
Gender:F
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 1:9615 HARVEST MOON LN APT 302
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-9676
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 N DEWEY AVE
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1049
Practice Address - Country:US
Practice Address - Phone:414-852-1726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4723-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant