Basic Information
| Provider Information | |||||||||
| NPI: | 1184612483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BANNON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | KARL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10970 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926850970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882629570 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 350 S OAK AVE | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953613519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098473011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 14220 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | 9179 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 9179 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363A00000X | 14220 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA14220 | 05 | CA | MEDICAID |