Provider Demographics
NPI:1457610255
Name:WOOD, BONNIE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:LYNN
Last Name:WOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 E RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4477
Mailing Address - Country:US
Mailing Address - Phone:435-656-0022
Mailing Address - Fax:435-634-8166
Practice Address - Street 1:1036 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4477
Practice Address - Country:US
Practice Address - Phone:435-656-0022
Practice Address - Fax:435-634-8166
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8250781-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8750781-1206OtherSTATE LICENSE NUMBER