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General NPI Number Information
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NPI Number | 1235177601
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Entity Type | Individual
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Provider Name | LISA CAMILLE BONIN PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/04/2006
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Last Update Date | 05/23/2024
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Provider Practice Location Address
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Address Line | 1700 E VENICE AVE
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City | VENICE
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State | FL
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Zip | 34292-3190
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Country | US
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Telephone | 941-483-9760
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Fax | 941-483-9775
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Provider Business Mailing Address
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Address Line | 2675 WINKLER AVE FL 2
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City | FORT MYERS
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State | FL
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Zip | 33901-9342
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Country | US
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Telephone | 877-856-3774
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Fax |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9114636
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License Number State | FL
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