Provider Demographics
NPI:1083618631
Name:BLEEKER, BONNIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:BLEEKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7600 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2985
Mailing Address - Country:US
Mailing Address - Phone:605-334-6730
Mailing Address - Fax:605-444-8289
Practice Address - Street 1:910 E 20TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-334-6730
Practice Address - Fax:605-334-8096
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0288363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6821228Medicaid
SD970021568Medicare PIN
SDP00008847Medicare PIN
SDS41187Medicare PIN
SDR74977Medicare UPIN