Provider Demographics
NPI:1013233758
Name:CULLISON BONNER, PHILLIP M (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:M
Last Name:CULLISON BONNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31001 NE TIMMEN RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-7709
Mailing Address - Country:US
Mailing Address - Phone:317-225-0388
Mailing Address - Fax:
Practice Address - Street 1:2211 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2742
Practice Address - Country:US
Practice Address - Phone:360-487-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD163266207R00000X
AK7734208M00000X
WAMD60648236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist