Provider Demographics
NPI:1598838518
Name:BONHAM, STEPHANIE LYNN (PA-C, MS, MPT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:BONHAM
Suffix:
Gender:F
Credentials:PA-C, MS, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 N DUKE ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2102
Mailing Address - Country:US
Mailing Address - Phone:919-660-2358
Mailing Address - Fax:919-660-8565
Practice Address - Street 1:3116 N DUKE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2102
Practice Address - Country:US
Practice Address - Phone:919-660-2358
Practice Address - Fax:919-660-8568
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMB1488433OtherDEA REGISTRATION NUMBER