Provider Demographics
NPI:1063016566
Name:BOHNEY, MICHAEL JASON (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JASON
Last Name:BOHNEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8483 HICKORY HILL TRL
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-8238
Mailing Address - Country:US
Mailing Address - Phone:317-771-6822
Mailing Address - Fax:
Practice Address - Street 1:500 E 109TH AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:219-921-1444
Practice Address - Fax:219-921-5303
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10003172363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant