Basic Information
| Provider Information | |||||||||
| NPI: | 1215431960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONUS | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | LUCK | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCK | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | OREGON HEALTH & SCIENCE UNVERSITY | ||||||||
| Address2: | 3181 SW SAM JACKSON PARK RD | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034184500 | ||||||||
| FaxNumber: | 5034941678 | ||||||||
| Practice Location | |||||||||
| Address1: | OREGON HEALTH & SCIENCE UNIVERSITY | ||||||||
| Address2: | 3181 SW SAM JACKSON PARK RD | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129262000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD209009 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.