Healthcare Provider Details

I. General information

NPI: 1124123120
Provider Name (Legal Business Name): BONNIE WHITE MARSH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR # 112
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

1 VETERANS DR # 112
MINNEAPOLIS MN
55417-2309
US

V. Phone/Fax

Practice location:
  • Phone: 612-725-2148
  • Fax: 612-725-1920
Mailing address:
  • Phone: 612-725-2148
  • Fax: 612-725-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9078
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: