Provider Demographics
NPI:1548378201
Name:GILBERTSON, BONITA L (NP)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:L
Last Name:GILBERTSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:BONITA
Other - Middle Name:L
Other - Last Name:MOISIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 WEST BARAGA AVENUE SUITE 30
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-225-3914
Mailing Address - Fax:906-225-4583
Practice Address - Street 1:850 WEST BARAGA AVENUE SUITE 30
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-225-3914
Practice Address - Fax:906-225-4583
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704201809163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI33393472Medicaid
MI0870871OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0E26047009Medicare PIN
MI0870871OtherBLUE CROSS BLUE SHIELD OF MICHIGAN