Provider Demographics
NPI:1114244498
Name:DITTMANN, BONNIE MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:MARIE
Last Name:DITTMANN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:BONNIE
Other - Middle Name:MARIE
Other - Last Name:HAYSLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2105 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1712
Mailing Address - Country:US
Mailing Address - Phone:828-773-1166
Mailing Address - Fax:541-429-6612
Practice Address - Street 1:2011 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2511
Practice Address - Country:US
Practice Address - Phone:541-963-4139
Practice Address - Fax:541-429-6612
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA151196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR171721Medicare UPIN