Provider Demographics
NPI:1932109204
Name:HUCKABY, BONNIE SCHULTZ (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:SCHULTZ
Last Name:HUCKABY
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 LAKE BREEZE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132
Mailing Address - Country:US
Mailing Address - Phone:817-707-0707
Mailing Address - Fax:
Practice Address - Street 1:1971 E 4TH ST STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3917
Practice Address - Country:US
Practice Address - Phone:888-959-5192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328451501Medicaid
TXQ58263Medicare UPIN
TX328451501Medicaid