Provider Demographics
NPI:1578504189
Name:THORSEN, BONNIE C (PAC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:C
Last Name:THORSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:C
Other - Last Name:BENNWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:444 E TIMBER DR
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-2852
Mailing Address - Country:US
Mailing Address - Phone:715-342-7765
Mailing Address - Fax:
Practice Address - Street 1:444 E TIMBER DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-2852
Practice Address - Country:US
Practice Address - Phone:715-342-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41996600Medicaid