Provider Demographics
NPI:1912361635
Name:BONNESEN, JAMES QUINTON
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:QUINTON
Last Name:BONNESEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13716 E MAINSGATE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67228-8049
Mailing Address - Country:US
Mailing Address - Phone:801-358-3420
Mailing Address - Fax:
Practice Address - Street 1:13716 E MAINSGATE STREET
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67228-8049
Practice Address - Country:US
Practice Address - Phone:801-358-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR097997163W00000X
KS557425367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse