Provider Demographics
NPI:1720052681
Name:BABONIS, BRIAN G (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:G
Last Name:BABONIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 E END BLVD
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-0030
Mailing Address - Country:US
Mailing Address - Phone:570-824-3521
Mailing Address - Fax:570-855-7065
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:
Practice Address - City:PLAINS TWP
Practice Address - State:PA
Practice Address - Zip Code:18702-7923
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:570-855-7065
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001926L363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S54179Medicare UPIN
PA008169Medicare ID - Type Unspecified