Healthcare Provider Details

I. General information

NPI: 1558368316
Provider Name (Legal Business Name): OTTO JOSEPH BONIN JR. NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 INDEPENDENCE BLVD 1A
ZACHARY LA
70791-7391
US

IV. Provider business mailing address

1215 INDEPENDENCE BLVD 1A
ZACHARY LA
70791-7391
US

V. Phone/Fax

Practice location:
  • Phone: 225-570-2010
  • Fax: 225-570-8573
Mailing address:
  • Phone: 225-570-2010
  • Fax: 225-570-8573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN085359 - AP04429
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: