Provider Demographics
NPI:1396764841
Name:BONASSO, MARK A (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BONASSO
Suffix:
Gender:M
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 1:950 S BAILEY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-8744
Mailing Address - Country:US
Mailing Address - Phone:269-639-2866
Mailing Address - Fax:
Practice Address - Street 1:950 S BAILEY AVE STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8744
Practice Address - Country:US
Practice Address - Phone:269-639-2866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003771OtherPHYS. ASST. LICENSE
MI38-1676780OtherEIN
MI0N44940Medicare ID - Type Unspecified
MI0H06003Medicare PIN
MIP51958Medicare UPIN