Provider Demographics
NPI:1841363306
Name:BONARE, SANDAE (CNM)
Entity type:Individual
Prefix:
First Name:SANDAE
Middle Name:
Last Name:BONARE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-408-1440
Mailing Address - Fax:801-408-1441
Practice Address - Street 1:324 10TH AVE
Practice Address - Street 2:STE 184
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2853
Practice Address - Country:US
Practice Address - Phone:801-408-1440
Practice Address - Fax:801-408-1441
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2128424402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
000064838Medicare PIN
UT005818305Medicare PIN
UT006996004Medicare PIN