Provider Demographics
NPI:1316983794
Name:WOELTJEN, BONNIE (PA)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:WOELTJEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 FANNIN ST
Mailing Address - Street 2:SCURLOCK TOWER, SUITE 400
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-441-9000
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SCURLOCK TOWER, SUITE 400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-441-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01068934OtherRR MEDICARE
616771101OtherUS DEPT OF LABOR
TXP00278999OtherRAILROAD MEDICARE
616771110OtherUS DEPT OF LABOR
TX331364501Medicaid
616771105OtherUS DEPT OF LABOR
TX8N8791OtherBLUE CROSS BLUE SHIELD
TXP01253331OtherMEDICARE RR
601771109OtherUS DEPT OF LABOR
601771109OtherUS DEPT OF LABOR
8G2250Medicare PIN
616771105OtherUS DEPT OF LABOR
TX331364501Medicaid