Basic Information
Provider Information | |||||||||
NPI: | 1407155070 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONIN | ||||||||
FirstName: | REAGAN | ||||||||
MiddleName: | DARICE NOVAK | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | CHARLES WILSON OUTPATIENT VA CLINIC | ||||||||
Address2: | 2206 N JOHN REDDITT DR. | ||||||||
City: | LUFKIN | ||||||||
State: | TX | ||||||||
PostalCode: | 75904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3696714300 | ||||||||
FaxNumber: | 9366714323 | ||||||||
Practice Location | |||||||||
Address1: | CHARLES WILSON OUTPATIENT CLINIC | ||||||||
Address2: | 2206 N JOHN REDDITT DR | ||||||||
City: | LUFKIN | ||||||||
State: | TX | ||||||||
PostalCode: | 75904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9366714300 | ||||||||
FaxNumber: | 9366714323 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2011 | ||||||||
LastUpdateDate: | 10/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD.207258 | LA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.