Basic Information
| Provider Information | |||||||||
| NPI: | 1114244498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITTMANN | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAYSLETT | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2105 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287731166 | ||||||||
| FaxNumber: | 5414296612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2011 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978502511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419634139 | ||||||||
| FaxNumber: | 5414296612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA151196 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.