Provider Demographics
NPI:1144001579
Name:BANUELOS, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 W HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-4105
Mailing Address - Country:US
Mailing Address - Phone:316-882-6035
Mailing Address - Fax:
Practice Address - Street 1:949 S GLENDALE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3210
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:316-239-2747
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
276840156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic