Provider Demographics
NPI:1013103639
Name:OMEARA, BONNIE SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:SUSAN
Last Name:OMEARA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10776 SUNSET RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2380
Mailing Address - Country:US
Mailing Address - Phone:858-578-7189
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-5004
Practice Address - Country:US
Practice Address - Phone:858-534-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292148363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health