Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 2000029735 | SD |
Y | 213ES0000X | Sports Medicine | 2000029735 | SD |
NPI | 1043732993 |
---|---|
Provider Name | Cody Lucas Bonte |
First Address | Mitchell, SD 57301-3311 |
Second Address | Mitchell, SD 57301-4358 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2017 |
Last Update Date | 12/07/2017 |