Healthcare Provider Details

I. General information

NPI: 1134213978
Provider Name (Legal Business Name): SHAWN PATRICK BONILLA N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 E VETERANS MEMORIAL HWY
BLANCHARD OK
73010-9215
US

IV. Provider business mailing address

PO BOX 5908
NORMAN OK
73070-5908
US

V. Phone/Fax

Practice location:
  • Phone: 405-659-5656
  • Fax: 405-701-5421
Mailing address:
  • Phone: 405-659-5656
  • Fax: 405-701-5421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberROO68442
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: