Healthcare Provider Details

I. General information

NPI: 1174032122
Provider Name (Legal Business Name): CARLOS EDUARDO BONILLA APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CARLOS EDUARDO BONILLA APRN

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1443 WEST 800 NORTH, SUITE #302
OREM UT
84057-3658
US

IV. Provider business mailing address

3527 NEWLAND LOOP
LEHI UT
84043-4617
US

V. Phone/Fax

Practice location:
  • Phone: 801-235-0953
  • Fax:
Mailing address:
  • Phone: 801-592-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5250948-4405
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: