Provider Demographics
NPI:1841271897
Name:BONNER, MADONNA KAY (PAC)
Entity type:Individual
Prefix:MRS
First Name:MADONNA
Middle Name:KAY
Last Name:BONNER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:MADONNA
Other - Middle Name:KAY
Other - Last Name:VARCHETTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:720 BEVERLY PIKE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-9205
Mailing Address - Country:US
Mailing Address - Phone:304-636-4585
Mailing Address - Fax:304-637-4588
Practice Address - Street 1:720 BEVERLY PIKE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-9205
Practice Address - Country:US
Practice Address - Phone:304-636-4585
Practice Address - Fax:304-637-4588
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001837930OtherMTN STATE SERVICE NUMBER
WV734619OtherNCPPO PROVIDER
WV001837930OtherMT ST BCBS SERVICE PROVIDER #
WV3000318OtherBRICKSTREET WORKERS COMP
WVFQ400OtherHEALTH PLAN PROVIDER NO.
WV001804181OtherMTN STATE BC/BS PAY TO 1
WV1023337OtherNCCPA
WVP00328118OtherRAILROAD MEDICARE
WV001967359OtherMTN STATE BC/BS PAY TO 2
WV3810005145Medicaid
WV00400OtherWVBOM PA-C LICENSE
WVWV400OtherHEALTH PLAN
WVWV400OtherHEALTH PLAN
WV001837930OtherMT ST BCBS SERVICE PROVIDER #
WV3000318OtherBRICKSTREET WORKERS COMP
WVWV400OtherHEALTH PLAN
WV1023337OtherNCCPA