Provider Demographics
NPI:1528036696
Name:GRUNDEL, BONNIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:GRUNDEL
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 1:550 REDSTONE AVE W STE 490
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6457
Mailing Address - Country:US
Mailing Address - Phone:850-689-8321
Mailing Address - Fax:850-689-8322
Practice Address - Street 1:369 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3541
Practice Address - Country:US
Practice Address - Phone:850-398-6963
Practice Address - Fax:850-398-8277
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY015KOtherBLUE CROSS BLUE SHIELD
FL17667OtherHEALTH FIRST NETWORK
FLP986780OtherFREEDOM HEALTH
FL291926500Medicaid
FLP931666OtherOPTIMUM
AL123872 CRESTVIEWMedicaid
FLP00900587OtherRAILROAD MCR
AL123873 SANTA ROSAMedicaid
FLE3504ZMedicare ID - Type Unspecified
AL123872 CRESTVIEWMedicaid
FL17667OtherHEALTH FIRST NETWORK
FL291926500Medicaid