Provider Demographics
NPI:1922035179
Name:RYAN, BONNIE BASS (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:BASS
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
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 512
Mailing Address - Street 2:
Mailing Address - City:ETOILE
Mailing Address - State:TX
Mailing Address - Zip Code:75944-0512
Mailing Address - Country:US
Mailing Address - Phone:936-465-5436
Mailing Address - Fax:
Practice Address - Street 1:2106 NORTH RAGUET STREET
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75962-4437
Practice Address - Country:US
Practice Address - Phone:936-468-4008
Practice Address - Fax:936-468-1316
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03470363A00000X, 363AM0700X
TXPA 03470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA03470OtherSTATE PA LICENSE NUMBER
TXP75843Medicare UPIN