Individual
MS. BONNIE MERRITT WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
3304 COOLEY CT, PORTAGE, MI 49024-7430
(269) 349-2266
(269) 349-0792
Mailing address
3304 COOLEY CT, PORTAGE, MI 49024-7430
(269) 349-2266
(269) 349-0792
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5601006513
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1417961137
BCBSM - BMH
MI
05
—
1437402229
—
MI
01
—
5601006513
PHYSICIAN'S ASSISTANT LICENSE
MI
Enumeration date
10/18/2012
Last updated
10/12/2014
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