Healthcare Provider Details

I. General information

NPI: 1629914932
Provider Name (Legal Business Name): MICHAEL ANTHONY BONNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4295 GESNER ST STE 1B
SAN DIEGO CA
92117-6626
US

IV. Provider business mailing address

13021 WANESTA DR
POWAY CA
92064-4507
US

V. Phone/Fax

Practice location:
  • Phone: 858-829-3205
  • Fax:
Mailing address:
  • Phone: 858-829-3205
  • Fax: 858-829-3205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number101233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: