Provider Demographics
NPI:1013213180
Name:BONSACK, CAMERA (CST II)
Entity Type:Individual
Prefix:
First Name:CAMERA
Middle Name:
Last Name:BONSACK
Suffix:
Gender:F
Credentials:CST II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 E GRANGER AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4545
Mailing Address - Country:US
Mailing Address - Phone:209-585-4610
Mailing Address - Fax:209-525-4590
Practice Address - Street 1:522 E GRANGER AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4545
Practice Address - Country:US
Practice Address - Phone:209-585-4610
Practice Address - Fax:209-525-4590
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker