Basic Information
| Provider Information | |||||||||
| NPI: | 1679063952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LO | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10624 S EASTERN AVE # A-955 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890522982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024077700 | ||||||||
| FaxNumber: | 7024077016 | ||||||||
| Practice Location | |||||||||
| Address1: | 10624 S EASTERN AVE # A-955 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890522982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024077700 | ||||||||
| FaxNumber: | 7023888431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2018 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | SL1338 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2861 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.