Healthcare Provider Details

I. General information

NPI: 1437292646
Provider Name (Legal Business Name): MICHAEL P BONNET PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 B VETERANS BLVD I-40, EXIT 102
ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 130 ATTN ACL PROVIDER ENROLLMENT
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5300
  • Fax: 505-552-5828
Mailing address:
  • Phone: 505-552-5300
  • Fax: 505-552-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2774
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: