Bonnie Merritt Wallace, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

5601006513 Issued in MI

Practice address

3304 Cooley CT
Portage, MI 49024-7430

Phone

(269) 349-2266

Fax

(269) 349-0792

NPI assigned

Oct 18, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1350518400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1413072000000",
    "number": "1437402229",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3304 COOLEY CT",
            "city": "PORTAGE",
            "state": "MI",
            "postal_code": "490247430",
            "telephone_number": "269-349-2266",
            "fax_number": "269-349-0792"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3304 COOLEY CT",
            "city": "PORTAGE",
            "state": "MI",
            "postal_code": "490247430",
            "telephone_number": "269-349-2266",
            "fax_number": "269-349-0792"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "BONNIE",
        "middle_name": "MERRITT",
        "name_prefix": "Ms.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-10-18",
        "last_updated": "2014-10-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MI",
            "license": "5601006513",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1437402229",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PHYSICIAN'S ASSISTANT LICENSE",
            "identifier": "5601006513",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSM - BMH",
            "identifier": "1417961137",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Larry R Walton
• Stephani Walton

• Physician Assistant in Portage, MI
• Providers in Portage, MI by specialty
• Physician Assistant in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 12, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.