Provider Demographics
NPI:1144861154
Name:BANANOV, BARBARA (PT,DPT)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:BANANOV
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1814
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1814
Mailing Address - Country:US
Mailing Address - Phone:212-444-2678
Mailing Address - Fax:
Practice Address - Street 1:39 6TH AVE # 3304
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0470
Practice Address - Country:US
Practice Address - Phone:212-444-2678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ013382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist