Provider Demographics
NPI:1235177601
Name:BONIN, LISA CAMILLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CAMILLE
Last Name:BONIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:1287 US HIGHWAY 41 BYP S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5545
Practice Address - Country:US
Practice Address - Phone:941-244-5716
Practice Address - Fax:941-800-4342
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00446Medicare UPIN
NJ084742Medicare ID - Type Unspecified