Provider Demographics
NPI:1992031124
Name:BANU, DIMITRINA (RPA-C)
Entity Type:Individual
Prefix:
First Name:DIMITRINA
Middle Name:
Last Name:BANU
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 ORLEANS ST
Mailing Address - Street 2:SHEIKH ZAYED TOWER ROOM 6118
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0010
Mailing Address - Country:US
Mailing Address - Phone:914-707-2138
Mailing Address - Fax:
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:C/O FACULTY PRACTICE MANAGEMENT- SUITE 1-37 NORTH
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:718-963-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0031522363A00000X
MDC0004445363AS0400X
NY013532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03210226Medicaid
NYA400018299Medicare PIN