Provider Demographics
NPI:1639120207
Name:BONNER, SEAN DOUGLAS (PA)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:DOUGLAS
Last Name:BONNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17222 HOSPITAL BLVD STE 242
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-8925
Mailing Address - Country:US
Mailing Address - Phone:352-683-0007
Mailing Address - Fax:
Practice Address - Street 1:17222 HOSPITAL BLVD STE 242
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8925
Practice Address - Country:US
Practice Address - Phone:352-683-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101895363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291189200Medicaid
FLN223336OtherWELLCARE
FL291189200Medicaid
FLN223336OtherWELLCARE