Healthcare Provider Details

I. General information

NPI: 1275774440
Provider Name (Legal Business Name): JONATHAN RENE BRONISTE APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S DIVISION ST
LAVACA AR
72941-4129
US

IV. Provider business mailing address

603 S DIVISION ST
LAVACA AR
72941-4129
US

V. Phone/Fax

Practice location:
  • Phone: 479-674-9181
  • Fax: 479-674-8105
Mailing address:
  • Phone: 479-674-9181
  • Fax: 479-674-8105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA03206
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: