Provider Demographics
NPI:1336164201
Name:BONNER, DIANNE L (PA-C)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:L
Last Name:BONNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7780 S BROADWAY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80122-2648
Mailing Address - Country:US
Mailing Address - Phone:303-734-8650
Mailing Address - Fax:303-734-8653
Practice Address - Street 1:7780 S BROADWAY
Practice Address - Street 2:SUITE 350
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-2648
Practice Address - Country:US
Practice Address - Phone:303-734-8650
Practice Address - Fax:303-734-8653
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2676363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06607519Medicaid
COCO304631Medicare PIN
COC477738Medicare PIN