Healthcare Provider Details

I. General information

NPI: 1326761966
Provider Name (Legal Business Name): JESSE BONTRAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S NEW ST
DOVER DE
19904-3571
US

IV. Provider business mailing address

740 S NEW ST
DOVER DE
19904-3571
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-0222
  • Fax: 302-674-0200
Mailing address:
  • Phone: 302-674-0222
  • Fax: 302-674-0200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0012133
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: