Provider Demographics
NPI:1962825356
Name:BONNER, MARIAH WALKER (DO)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:WALKER
Last Name:BONNER
Suffix:
Gender:F
Credentials:DO
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 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-273-4923
Mailing Address - Fax:
Practice Address - Street 1:5549 US HIGHWAY 93 N
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MT
Practice Address - Zip Code:59833-6845
Practice Address - Country:US
Practice Address - Phone:406-273-4923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT69131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine