Provider Demographics
NPI:1134176191
Name:MULLER, BONNIE LISLE (PA)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:LISLE
Last Name:MULLER
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 1:707 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-1072
Mailing Address - Country:US
Mailing Address - Phone:712-542-5907
Mailing Address - Fax:
Practice Address - Street 1:823 S 17TH ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2625
Practice Address - Country:US
Practice Address - Phone:712-542-8330
Practice Address - Fax:712-542-3373
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS00943Medicare UPIN
IAI16582Medicare ID - Type Unspecified