Provider Demographics
NPI:1417300096
Name:BONILLA, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 REILLY ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-8922
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:1608 S. KINGS HWY
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607
Practice Address - Country:US
Practice Address - Phone:520-805-8162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical