Healthcare Provider Details

I. General information

NPI: 1932109204
Provider Name (Legal Business Name): BONNIE SCHULTZ HUCKABY MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 09/29/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1971 E 4TH ST STE 200
SANTA ANA CA
92705-3917
US

IV. Provider business mailing address

4301 LAKE BREEZE CT
FORT WORTH TX
76132
US

V. Phone/Fax

Practice location:
  • Phone: 888-959-5192
  • Fax:
Mailing address:
  • Phone: 817-707-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04247
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: