Provider Demographics
NPI:1538687272
Name:BONEN, MICHAEL G
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:BONEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7701 E EAST CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7001
Mailing Address - Country:US
Mailing Address - Phone:816-547-5321
Mailing Address - Fax:
Practice Address - Street 1:404 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6626
Practice Address - Country:US
Practice Address - Phone:573-771-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOP11730146L00000X
MO2010016740163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic