Provider Demographics
NPI:1558368316
Name:BONIN, OTTO JOSEPH JR (NP)
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:JOSEPH
Last Name:BONIN
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 INDEPENDENCE BLVD 1A
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7391
Mailing Address - Country:US
Mailing Address - Phone:225-570-2010
Mailing Address - Fax:225-570-8573
Practice Address - Street 1:1215 INDEPENDENCE BLVD 1A
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7391
Practice Address - Country:US
Practice Address - Phone:225-570-2010
Practice Address - Fax:225-570-8573
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN085359 - AP04429363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00089352OtherRR MEDICARE
LA1069311Medicaid
LA1069311Medicaid
LAP00089352OtherRR MEDICARE