Basic Information
| Provider Information | |||||||||
| NPI: | 1336318443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANKSTON | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | CRAIN | ||||||||
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| OtherLastName: | WASCOM | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14465 WILSON MAGEE RD | ||||||||
| Address2: | |||||||||
| City: | BOGALUSA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704277367 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 206 MARYLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396483926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012504815 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2008 | ||||||||
| LastUpdateDate: | 02/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 06552R | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.