Basic Information
Provider Information | |||||||||
NPI: | 1740617141 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONUS | ||||||||
FirstName: | ROSALIE | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | ROSALIE | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11279 PERRY HWY | ||||||||
Address2: | SUITE 450 | ||||||||
City: | WEXFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 150909381 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7249331100 | ||||||||
FaxNumber: | 7249331160 | ||||||||
Practice Location | |||||||||
Address1: | 3580 PEACH ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165082776 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8148689633 | ||||||||
FaxNumber: | 8148661436 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2013 | ||||||||
LastUpdateDate: | 10/24/2019 | ||||||||
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 | 363A00000X | MA056367 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.