Provider Demographics
NPI:1770762429
Name:BONNVILLE, HEATHER K (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:K
Last Name:BONNVILLE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MRS
Other - First Name:HEATHER
Other - Middle Name:K
Other - Last Name:GROOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:661 W 1ST ST STE G
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2939
Mailing Address - Country:US
Mailing Address - Phone:714-665-9890
Mailing Address - Fax:714-665-9891
Practice Address - Street 1:661 W 1ST ST STE G
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2939
Practice Address - Country:US
Practice Address - Phone:714-665-9890
Practice Address - Fax:714-665-9891
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770762429Medicaid