Provider Demographics
NPI:1487880126
Name:BANKS, WACHOVIA CHANTA' (DO)
Entity type:Individual
Prefix:DR
First Name:WACHOVIA
Middle Name:CHANTA'
Last Name:BANKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:WACHOVIA
Other - Middle Name:CHANTA'
Other - Last Name:RIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5800 BRUNSWICK CT
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70131-5425
Mailing Address - Country:US
Mailing Address - Phone:717-880-3740
Mailing Address - Fax:
Practice Address - Street 1:1175 GREY PINE DR
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-7320
Practice Address - Country:US
Practice Address - Phone:803-995-5599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT013286207P00000X, 208D00000X
SC51870207Q00000X
390200000X
LACOVID19-TMP-211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC518700Medicaid
LA2570986Medicaid