Provider Demographics
NPI:1740389485
Name:BONASSO, PATRICK CORKREAN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:CORKREAN
Last Name:BONASSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1320
Mailing Address - Country:US
Mailing Address - Phone:304-366-6100
Mailing Address - Fax:304-366-2220
Practice Address - Street 1:1703 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1320
Practice Address - Country:US
Practice Address - Phone:304-366-6100
Practice Address - Fax:304-366-2220
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV13108207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0094765000Medicaid
WVA72386Medicare UPIN
WV0094765000Medicaid