Provider Demographics
NPI:1770546962
Name:BALDWIN, BONITA E (PA-C)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:E
Last Name:BALDWIN
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 1:14717 STILLWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-6046
Mailing Address - Country:US
Mailing Address - Phone:440-773-6057
Mailing Address - Fax:
Practice Address - Street 1:3999 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6046
Practice Address - Country:US
Practice Address - Phone:216-593-1290
Practice Address - Fax:216-593-1651
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001237363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBAPA79961Medicare ID - Type Unspecified
OHQ71654Medicare UPIN