MEDICARE: BONNIE HEIKES P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA11327	CA

General Provider Information

NPI Number	:	1306975743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE HEIKES P.A.-C

Provider Business Mailing Address
First Line	:	705 GRAND AVE
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-2639
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 GRAND AVE
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-2639
Country	:	US
Telephone Number	:	805-544-2478
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2007
Last Update Date	:	07/08/2007

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