Provider Demographics
NPI:1134213978
Name:BONILLA, SHAWN PATRICK (NP)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:PATRICK
Last Name:BONILLA
Suffix:
Gender:M
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:PO BOX 5908
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-5908
Mailing Address - Country:US
Mailing Address - Phone:405-659-5656
Mailing Address - Fax:405-701-5421
Practice Address - Street 1:821 E VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-9215
Practice Address - Country:US
Practice Address - Phone:405-659-5656
Practice Address - Fax:405-701-5421
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKROO68442363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200226680AMedicaid