Provider Demographics
NPI:1831842343
Name:BIERBAUM, BONNIE BRIANNA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:BONNIE BRIANNA
Middle Name:ROSE
Last Name:BIERBAUM
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 1:1649 N PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-5207
Mailing Address - Country:US
Mailing Address - Phone:737-278-6868
Mailing Address - Fax:
Practice Address - Street 1:1649 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-5207
Practice Address - Country:US
Practice Address - Phone:773-278-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant