Provider Demographics
NPI:1275774440
Name:BRONISTE, JONATHAN RENE (APN)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RENE
Last Name:BRONISTE
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:LAVACA
Mailing Address - State:AR
Mailing Address - Zip Code:72941-4129
Mailing Address - Country:US
Mailing Address - Phone:479-674-9181
Mailing Address - Fax:479-674-8105
Practice Address - Street 1:603 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:LAVACA
Practice Address - State:AR
Practice Address - Zip Code:72941-4129
Practice Address - Country:US
Practice Address - Phone:479-674-9181
Practice Address - Fax:479-674-8105
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03206363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA03206OtherLICENSE NUMBER