Provider Demographics
NPI:1184612483
Name:O'BANNON, BRIAN KARL (PA-C, FNP)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KARL
Last Name:O'BANNON
Suffix:
Gender:M
Credentials:PA-C, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10970
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-0970
Mailing Address - Country:US
Mailing Address - Phone:888-262-9570
Mailing Address - Fax:
Practice Address - Street 1:350 S OAK AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3519
Practice Address - Country:US
Practice Address - Phone:209-847-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14220363AM0700X, 363A00000X
CA9179363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14220Medicaid
S88467Medicare UPIN
CAPA14220Medicaid
CAAT818ZMedicare PIN