Provider Demographics
NPI:1104029545
Name:HUBER, BONNIE SUZANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:SUZANNE
Last Name:HUBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12607 SE MILL PLAIN BLVD
Mailing Address - Street 2:NORTHWEST PERMANENTE
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6055
Mailing Address - Country:US
Mailing Address - Phone:360-896-4460
Mailing Address - Fax:360-896-4478
Practice Address - Street 1:12607 SE MILL PLAIN BLVD
Practice Address - Street 2:NORTHWEST PERMANENTE
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6055
Practice Address - Country:US
Practice Address - Phone:360-896-4460
Practice Address - Fax:360-896-4478
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 142342084P0800X
WAMD 603416052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN