Provider Demographics
NPI:1508896762
Name:GAWEL, BONITA H (PAC)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:H
Last Name:GAWEL
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:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-742-4583
Mailing Address - Fax:989-742-4298
Practice Address - Street 1:15774 STATE STREET
Practice Address - Street 2:
Practice Address - City:HILLMAN
Practice Address - State:MI
Practice Address - Zip Code:49746-8818
Practice Address - Country:US
Practice Address - Phone:989-742-4583
Practice Address - Fax:989-742-4298
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF06016061Medicare PIN
P21305Medicare UPIN