=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609419183
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN SCOTT BONEWELL CNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2019
-----------------------------------------------------
Last Update Date | 10/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 JASMINE ST
-----------------------------------------------------
City | OMAK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98841-9578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-826-1760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 VIEWMONT
-----------------------------------------------------
City | OKANOGAN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98840-9424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-559-8580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP61006049
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------