Provider Demographics
NPI:1437402229
Name:WALLACE, BONNIE MERRITT (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:MERRITT
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 COOLEY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7430
Mailing Address - Country:US
Mailing Address - Phone:269-349-2266
Mailing Address - Fax:269-349-0792
Practice Address - Street 1:3304 COOLEY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7430
Practice Address - Country:US
Practice Address - Phone:269-349-2266
Practice Address - Fax:269-349-0792
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2014-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437402229Medicaid
MI5601006513OtherPHYSICIAN'S ASSISTANT LICENSE
MI1417961137OtherBCBSM - BMH
MIC97618363 - BMHMedicare PIN