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General NPI Number Information
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NPI Number | 1396058608
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Entity Type | Individual
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Provider Name | JACK E BONHAM PA
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Gender | Male
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Dates
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Enumeration Date | 07/16/2010
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Last Update Date | 06/25/2021
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Provider Practice Location Address
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Address Line | 1600 ALBANY ST
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City | BEECH GROVE
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State | IN
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Zip | 46107-1541
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Country | US
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Telephone | 317-802-3151
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Fax | 317-870-0499
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Provider Business Mailing Address
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Address Line | PO BOX 7112 DPT 31
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City | INDIANAPOLIS
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State | IN
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Zip | 46207-7112
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Country | US
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Telephone | 317-802-3151
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Fax | 317-870-0499
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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 | 10001193A
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License Number State | IN
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