Basic Information
| Provider Information | |||||||||
| NPI: | 1164421954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONTHUIS | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA--C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOUVIERE | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198743000 | ||||||||
| FaxNumber: | 3198743411 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192724300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 000826 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0076372 | 05 | IA | MEDICAID | 0184473 | 05 | IA | MEDICAID | IA0133 | 01 | JOHN DEERE HEALTH CARE | OTHER |