Provider Demographics
NPI:1265278758
Name:BANAHAN, AMY SUE (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:BANAHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 OLD QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:SELKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:12158-2109
Mailing Address - Country:US
Mailing Address - Phone:518-801-7286
Mailing Address - Fax:
Practice Address - Street 1:1499 NEW SCOTLAND RD
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9209
Practice Address - Country:US
Practice Address - Phone:518-801-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY354268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine