Provider Demographics
NPI:1073326476
Name:BANASZAK, JEFFREY STEPHEN (PT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:STEPHEN
Last Name:BANASZAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ROGERS CT
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-3167
Mailing Address - Country:US
Mailing Address - Phone:817-277-1458
Mailing Address - Fax:
Practice Address - Street 1:6 ROGERS CT
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-3167
Practice Address - Country:US
Practice Address - Phone:817-277-1458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11684922251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty