1013217983 NPI number — MRS. TINA OVIGUE BONKAT L.P.N

Table of content: MRS. TINA OVIGUE BONKAT L.P.N (NPI 1013217983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013217983 NPI number — MRS. TINA OVIGUE BONKAT L.P.N

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONKAT
Provider First Name:
TINA
Provider Middle Name:
OVIGUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.P.N
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ERUAGBERE
Provider Other First Name:
AUGUSTINA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013217983
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1108 VILLAGE ROAD
Provider Second Line Business Mailing Address:
APT 16D
Provider Business Mailing Address City Name:
CHASKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-688-2345
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6711 14TH AVENUE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-688-2345
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  L64317-9 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)