Provider Demographics
NPI:1164823977
Name:HANSON, BONNIE MCMANAMON
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:MCMANAMON
Last Name:HANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 HOUMA BLVD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2429
Mailing Address - Country:US
Mailing Address - Phone:504-503-6781
Mailing Address - Fax:504-503-5667
Practice Address - Street 1:4228 HOUMA BLVD STE 130
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3003
Practice Address - Country:US
Practice Address - Phone:504-454-2222
Practice Address - Fax:504-454-2388
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08404301Medicaid
LA2380613Medicaid
LA2380613Medicaid