MEDICARE: BONNIE OVERHOLSER PA-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	363A00000X	Physician Assistant	1117	CO

General Provider Information

NPI Number	:	1962798371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE OVERHOLSER PA-C

Provider Business Mailing Address
First Line	:	1080 E ELIZABETH ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3953
Country	:	US
Telephone Number	:	970-493-6353
Fax Number	:	970-493-6366

Provider Business Practice Location Address
First Line	:	1080 E ELIZABETH ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3953
Country	:	US
Telephone Number	:	970-493-6353
Fax Number	:	970-493-6366

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

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	06/23/2011

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