Provider Demographics
NPI:1285772475
Name:BONNESEN, DOUGLAS ANDREW (PT)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ANDREW
Last Name:BONNESEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6407 E 39TH CT N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2455
Mailing Address - Country:US
Mailing Address - Phone:316-687-9240
Mailing Address - Fax:
Practice Address - Street 1:9727 E SHANNON WOODS CIR STE 160
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-4102
Practice Address - Country:US
Practice Address - Phone:316-681-0824
Practice Address - Fax:316-219-1349
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-01966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist