Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 7666 | SC |
Y | 2251X0800X | Physical Therapist - Orthopedic | 294555 | CA |
NPI | 1053702019 |
---|---|
Provider Name | Grant Allen Banks |
First Address | Roseville, CA 95661-4239 |
Second Address | Pinole, CA 94564-2524 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2015 |
Last Update Date | 24/04/2018 |