Provider Demographics
NPI:1952050015
Name:BANKS, DYLAN WADE
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:WADE
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 1:3300 N 7TH AVE UNIT 403
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4190
Mailing Address - Country:US
Mailing Address - Phone:774-271-1056
Mailing Address - Fax:
Practice Address - Street 1:3300 N 7TH AVE UNIT 403
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4190
Practice Address - Country:US
Practice Address - Phone:774-271-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program