Provider Demographics
NPI:1144254046
Name:OGDEN, BONNIE J (PA-C)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:J
Last Name:OGDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:133 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2308
Mailing Address - Country:US
Mailing Address - Phone:586-329-1880
Mailing Address - Fax:586-231-0055
Practice Address - Street 1:30795 23 MILE RD STE 201
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-5721
Practice Address - Country:US
Practice Address - Phone:586-421-1600
Practice Address - Fax:586-421-1800
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003396363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1144254046Medicaid
MION28530Medicare ID - Type Unspecified