Provider Demographics
NPI:1659354371
Name:BOLICK-BONIN, SUSAN M (PA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:BOLICK-BONIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:BONIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VANDLING
Mailing Address - State:PA
Mailing Address - Zip Code:18421-1711
Mailing Address - Country:US
Mailing Address - Phone:570-785-3194
Mailing Address - Fax:570-785-9775
Practice Address - Street 1:111 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANDLING
Practice Address - State:PA
Practice Address - Zip Code:18421-1711
Practice Address - Country:US
Practice Address - Phone:570-785-3194
Practice Address - Fax:570-785-9775
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000780363A00000X
PAMA050732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant