Provider Demographics
NPI:1003805110
Name:GAUDIN, BONNIE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:LYNN
Last Name:GAUDIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75332
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-0332
Mailing Address - Country:US
Mailing Address - Phone:336-768-5762
Mailing Address - Fax:
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-275-3325
Practice Address - Fax:336-275-5346
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1334111Medicaid
LA5CQ60P993Medicare PIN
Q61695Medicare UPIN