Provider Demographics
NPI:1174032122
Name:BONILLA, CARLOS EDUARDO (APRN)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:EDUARDO
Last Name:BONILLA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:EDUARDO
Other - Last Name:BONILLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:3527 NEWLAND LOOP
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4617
Mailing Address - Country:US
Mailing Address - Phone:801-592-9350
Mailing Address - Fax:
Practice Address - Street 1:1443 WEST 800 NORTH, SUITE #302
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3658
Practice Address - Country:US
Practice Address - Phone:801-235-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5250948-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily