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General NPI Number Information
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NPI Number | 1013213180
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Entity Type | Individual
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Provider Name | CAMERA BONSACK CST II
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Gender | Female
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Dates
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Enumeration Date | 02/07/2011
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Last Update Date | 05/16/2025
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Provider Practice Location Address
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Address Line | 800 SCENIC DR STE E
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City | MODESTO
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State | CA
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Zip | 95350-6131
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Country | US
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Telephone | 209-531-8016
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Fax | 209-525-4590
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Provider Business Mailing Address
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Address Line | 522 E GRANGER AVE
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City | MODESTO
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State | CA
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Zip | 95350-4545
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Country | US
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Telephone | 209-585-4610
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Fax | 209-525-4590
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | MPSS-PSQHDC
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License Number State | CA
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