Provider Demographics
NPI:1245438027
Name:BONNER, KIRBY E (PTA)
Entity type:Individual
Prefix:MISS
First Name:KIRBY
Middle Name:E
Last Name:BONNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 KAREN WAY
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-2989
Mailing Address - Country:US
Mailing Address - Phone:304-376-1812
Mailing Address - Fax:
Practice Address - Street 1:600 REUNION CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1610
Practice Address - Country:US
Practice Address - Phone:817-573-3773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA001299225200000X
FLPTA21595225200000X
TX2075579225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant