Healthcare Provider Details

I. General information

NPI: 1902106495
Provider Name (Legal Business Name): KEISHA PATRICE BONNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2010
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 MOUNT VERNON RD SE
CEDAR RAPIDS IA
52403-3326
US

IV. Provider business mailing address

1923 MOUNT VERNON RD SE
CEDAR RAPIDS IA
52403-3326
US

V. Phone/Fax

Practice location:
  • Phone: 319-560-5287
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number345208
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number296319
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: