Provider Demographics
NPI:1164421954
Name:BONTHUIS, HEIDI M (PA--C)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:M
Last Name:BONTHUIS
Suffix:
Gender:F
Credentials:PA--C
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:M
Other - Last Name:LOUVIERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:905 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-4407
Mailing Address - Country:US
Mailing Address - Phone:319-874-3000
Mailing Address - Fax:319-874-3411
Practice Address - Street 1:905 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-4407
Practice Address - Country:US
Practice Address - Phone:319-272-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076372Medicaid
IA0184473Medicaid
IA0133OtherJOHN DEERE HEALTH CARE
IA0184473Medicaid