Provider Demographics
NPI:1780632919
Name:BONNEVILLE, JOSEPH PAUL (PA)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:PAUL
Last Name:BONNEVILLE
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 1:4805 S MOORLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7401
Mailing Address - Country:US
Mailing Address - Phone:262-798-7200
Mailing Address - Fax:262-798-7201
Practice Address - Street 1:4805 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7401
Practice Address - Country:US
Practice Address - Phone:262-798-7200
Practice Address - Fax:262-798-7201
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI793-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42955600Medicaid
WI42955600Medicaid
WI006973601Medicare ID - Type Unspecified