Provider Demographics
NPI:1356803332
Name:BONNER, AJAY RAY
Entity type:Individual
Prefix:
First Name:AJAY
Middle Name:RAY
Last Name:BONNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:PANHANDLE
Mailing Address - State:TX
Mailing Address - Zip Code:79068-9805
Mailing Address - Country:US
Mailing Address - Phone:806-678-8881
Mailing Address - Fax:
Practice Address - Street 1:1405 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:PANHANDLE
Practice Address - State:TX
Practice Address - Zip Code:79068-9805
Practice Address - Country:US
Practice Address - Phone:806-678-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer