Provider Demographics
NPI:1831932243
Name:BANKSTON, BRETT (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:
Last Name:BANKSTON
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 1:18023 OLD TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-5586
Mailing Address - Country:US
Mailing Address - Phone:225-276-3618
Mailing Address - Fax:
Practice Address - Street 1:8888 SUMMA AVE FL 3
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3772
Practice Address - Country:US
Practice Address - Phone:225-763-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1197616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant