Basic Information
| Provider Information | |||||||||
| NPI: | 1831842343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIERBAUM | ||||||||
| FirstName: | BONNIE BRIANNA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2728 N HAMPDEN CT APT 1401 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606141627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252127902 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1649 N PULASKI RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606395207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732786868 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2022 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085008831 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.