Provider Demographics
NPI:1689836918
Name:BONAQUIST, CASEY RENEE (DO)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:RENEE
Last Name:BONAQUIST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:400 COLONNADE DR STE 160
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-6236
Practice Address - Country:US
Practice Address - Phone:904-824-6194
Practice Address - Fax:904-824-5333
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT013360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine