Basic Information
| Provider Information | |||||||||
| NPI: | 1225080336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONNER | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DESELM | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 716 ADAIR AVE | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437012836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408919000 | ||||||||
| FaxNumber: | 7408919001 | ||||||||
| Practice Location | |||||||||
| Address1: | 716 ADAIR AVE | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437012836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408919000 | ||||||||
| FaxNumber: | 7408919001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34006885 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 34-006885 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2136709 | 05 | OH | MEDICAID |