Provider Demographics
NPI:1720483530
Name:BANNER, NATHAN ALAN (RT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALAN
Last Name:BANNER
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N SUMMER ROSE ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6003
Mailing Address - Country:US
Mailing Address - Phone:208-277-5338
Mailing Address - Fax:
Practice Address - Street 1:1800 N SUMMER ROSE ST
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6003
Practice Address - Country:US
Practice Address - Phone:208-277-5338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID529099247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist