Basic Information
| Provider Information | |||||||||
| NPI: | 1366404543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINT | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTS | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 HAMPTON ROADS GASTROENTEROLOGY | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236666080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578263434 | ||||||||
| FaxNumber: | 7032959369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 0024166001 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P01168429 | 01 | VA | RAILROAD MEDICARE | OTHER | Q42522A | 01 | VA | PALMETTO MEDICARE | OTHER | 010184142 | 05 | VA | MEDICAID | 1366404543 | 05 | VA | MEDICAID |