Provider Demographics
NPI:1245262187
Name:WALTER, BONNIE AHRENS (PA-C)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:AHRENS
Last Name:WALTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 W ROSEDALE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7437
Mailing Address - Country:US
Mailing Address - Phone:817-930-2030
Mailing Address - Fax:
Practice Address - Street 1:1651 W ROSEDALE ST STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7437
Practice Address - Country:US
Practice Address - Phone:817-930-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02950363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187161801Medicaid
P00404027OtherRAILROAD MEDICARE
P00404027OtherRAILROAD MEDICARE
TX347007YKPWMedicare PIN
P57464Medicare UPIN