Healthcare Provider Details

I. General information

NPI: 1003805110
Provider Name (Legal Business Name): BONNIE LYNN GAUDIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SILAS CREEK PKWY EMERGENCY DEPARTMENT
WINSTON SALEM NC
27103-3013
US

IV. Provider business mailing address

PO BOX 75332
CHARLOTTE NC
28275-0332
US

V. Phone/Fax

Practice location:
  • Phone: 336-275-3325
  • Fax: 336-275-5346
Mailing address:
  • Phone: 336-768-5762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: