Provider Demographics
NPI:1982663209
Name:BANKSTON, SUSAN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BANKSTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 S HILL DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-4341
Mailing Address - Country:US
Mailing Address - Phone:228-594-1711
Mailing Address - Fax:
Practice Address - Street 1:3109 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4361
Practice Address - Country:US
Practice Address - Phone:228-818-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9175676367500000X
MSR854110367500000X
LAAP04993367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02072ZMedicare ID - Type Unspecified