Healthcare Provider Details

I. General information

NPI: 1154992162
Provider Name (Legal Business Name): ADAM BONSALL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E H ST
IRON MOUNTAIN MI
49801-4760
US

IV. Provider business mailing address

N3399 WOOD LAND DR
IRON MOUNTAIN MI
49801-9645
US

V. Phone/Fax

Practice location:
  • Phone: 906-774-3300
  • Fax:
Mailing address:
  • Phone: 906-282-5641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704356109
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: