Provider Demographics
NPI:1518193382
Name:BONTRAGER, DEREK CHRISTOPHER (CRCST,CFA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:CHRISTOPHER
Last Name:BONTRAGER
Suffix:
Gender:M
Credentials:CRCST,CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:525 N SWITZER CANYON DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4845
Mailing Address - Country:US
Mailing Address - Phone:928-773-2280
Mailing Address - Fax:928-773-2281
Practice Address - Street 1:525 N SWITZER CANYON DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4845
Practice Address - Country:US
Practice Address - Phone:928-773-2280
Practice Address - Fax:928-773-2281
Is Sole Proprietor?:No
Enumeration Date:2009-06-06
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ114919246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant