Provider Demographics
NPI:1497788939
Name:BONN, GAIL M (PAC)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:M
Last Name:BONN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 10TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1146
Mailing Address - Country:US
Mailing Address - Phone:605-845-3692
Mailing Address - Fax:605-845-8252
Practice Address - Street 1:1309 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-1146
Practice Address - Country:US
Practice Address - Phone:605-845-3692
Practice Address - Fax:605-845-8252
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S103976OtherPTAN
1497788939OtherNPI
SD6826040Medicaid
SD1497788939Medicaid
1497788939OtherNPI