Provider Demographics
NPI:1205976487
Name:BANNISTER, SEAN PATRICK ALONZA (PA-C)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK ALONZA
Last Name:BANNISTER
Suffix:
Gender:M
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 1:745 NW FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-1016
Mailing Address - Country:US
Mailing Address - Phone:772-247-7545
Mailing Address - Fax:772-264-3272
Practice Address - Street 1:745 NW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-1016
Practice Address - Country:US
Practice Address - Phone:772-247-7545
Practice Address - Fax:772-264-3272
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105846363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003293800Medicaid
FLY06THOtherBLUE CROSS BLUE SHIELD
FLES070YMedicare PIN
FLES070ZMedicare UPIN
FLES070WMedicare PIN
FLES070VMedicare PIN
FLES070XMedicare PIN