Provider Demographics
NPI:1396045241
Name:BONNER, EDDIE AMOS II (NP)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:AMOS
Last Name:BONNER
Suffix:II
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-5904
Mailing Address - Country:US
Mailing Address - Phone:325-657-5028
Mailing Address - Fax:
Practice Address - Street 1:120 E HARRIS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5904
Practice Address - Country:US
Practice Address - Phone:325-657-5028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX680179363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX838N75OtherBCBS
TX838N75OtherBCBS