Individual
MARIAH BONCEK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1430 OLIVE ST STE 100, SAINT LOUIS, MO 63103-2303
(314) 645-6840
Mailing address
1508 WELLS AVE, WEBSTER GROVES, MO 63119-5215
(317) 414-5953
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085.008253
STATE LICENSE
IL
01
—
2021012805
STATE LICENSE
MO
Enumeration date
03/30/2020
Last updated
05/17/2021
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