Provider Demographics
NPI:1437292646
Name:BONNET, MICHAEL P (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:BONNET
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:ATTN ACL PROVIDER ENROLLMENT
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:505-552-5828
Practice Address - Street 1:80 B VETERANS BLVD
Practice Address - Street 2:I-40, EXIT 102
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:505-552-5828
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NMH3451Medicaid