Basic Information
Provider Information | |||||||||
NPI: | 1043212616 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BANISTER | ||||||||
FirstName: | PAMELA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROBINSON | ||||||||
OtherFirstName: | PAMELA | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 840026 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752840026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8062126965 | ||||||||
FaxNumber: | 8062126278 | ||||||||
Practice Location | |||||||||
Address1: | 3501 S SONCY RD STE 150 | ||||||||
Address2: |   | ||||||||
City: | AMARILLO | ||||||||
State: | TX | ||||||||
PostalCode: | 791196426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8062126353 | ||||||||
FaxNumber: | 8062120558 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2005 | ||||||||
LastUpdateDate: | 09/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 12878 | MS | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | K7991 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 111959607 | 05 | TX |   | MEDICAID | 1D7229 | 01 | TX | MEDICARE | OTHER |