Jacob Bonilla
Individual provider Active NPI Medical Physician Assistant · Douglas, AZ
NPI 1417300096 · NPPES record last updated Mar 21, 2022
Key facts
- NPI
- 1417300096
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Medical Physician Assistant 363AM0700X
- Practice address
- 1608 S. Kings Hwy
Douglas, AZ 85607 - Phone
- (520) 805-8162
- NPI assigned
- Jul 19, 2016
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 4
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- Other, 2011
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Benson Hospital Corporation
Practice addresses (Care Compare)
450 S Ocotillo Ave
Benson, AZ 85602-6403
Phone (520) 586-2261
Hospital & facility affiliations
- Benson Hospital
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20250903000288 | AZ | Practitioner - Physician Assistant | 2365943008 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Benson Hospital Corporation | Current |
Accepting new patients |
Locations
450 S Ocotillo St
Benson, AZ 85602
Phone (520) 586-2261
890 W 4th St
Benson, AZ 85602
Phone (520) 586-3664
Interoperability endpoints
- jacob.bonilla.1@18129.direct.athenahealth.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | Yes |
Addresses
Primary practice location
1608 S. Kings Hwy
Douglas, AZ 85607
Mailing address
2817 Reilly St
Fort Bragg, NC 28310-8922
Phone (910) 907-8922
Other practice location 1
2817 Reilly St
Fort Bragg, NC 28310-8922
Phone (910) 907-8922
Other providers in Douglas, AZ
- Shirley L. Bayham-Hicks
- Karina Celeste Bechtold
- Brian Beltran
- Bisbee Hospital Association
- Bisbee Hospital Association
- Anne M. Brasher
- Dale Owen Bryan
- Stacey Calderon
- Natividad Cano
- Caring Connections for Special Needs, LLC
All providers in Douglas, AZ · Medical Physician Assistant in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 21, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.