Provider Demographics
NPI:1548309495
Name:BAIN, LONNIEL JASON (NP)
Entity type:Individual
Prefix:
First Name:LONNIEL
Middle Name:JASON
Last Name:BAIN
Suffix:
Gender:M
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:457 MCLAWS CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5645
Practice Address - Country:US
Practice Address - Phone:757-221-0750
Practice Address - Fax:757-229-5168
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-09-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0024166074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1548309495Medicaid
VAMC11654Medicare PIN
VA1548309495Medicaid
VAP00670723Medicare PIN