Provider Demographics
NPI:1245204767
Name:RILEY, BONNIE JEAN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:JEAN
Last Name:RILEY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5274
Mailing Address - Country:US
Mailing Address - Phone:912-435-5872
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVENUE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5274
Practice Address - Country:US
Practice Address - Phone:912-435-5872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant