Provider Demographics
NPI:1447406988
Name:BONNER, SUSAN S (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:BONNER
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:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:GWYNN
Mailing Address - State:VA
Mailing Address - Zip Code:23066-0187
Mailing Address - Country:US
Mailing Address - Phone:804-725-1613
Mailing Address - Fax:
Practice Address - Street 1:2276 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:HAYES
Practice Address - State:VA
Practice Address - Zip Code:23072-3559
Practice Address - Country:US
Practice Address - Phone:804-642-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840847363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant