Provider Demographics
NPI:1508580119
Name:BUNAL, BENEDICT MARK M (NP)
Entity Type:Individual
Prefix:MR
First Name:BENEDICT MARK
Middle Name:M
Last Name:BUNAL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12045 SE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5214
Mailing Address - Country:US
Mailing Address - Phone:904-763-6796
Mailing Address - Fax:
Practice Address - Street 1:18633 SE STARK ST STE 401
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5468
Practice Address - Country:US
Practice Address - Phone:503-489-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202215281NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily