Healthcare Provider Details

I. General information

NPI: 1578525697
Provider Name (Legal Business Name): HANA BONEFACIC M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6341 UNIVERSITY AVE NE
FRIDLEY MN
55432-4946
US

IV. Provider business mailing address

6401 UNIVERSITY AVE NE
FRIDLEY MN
55432-4341
US

V. Phone/Fax

Practice location:
  • Phone: 763-572-5710
  • Fax: 763-586-5955
Mailing address:
  • Phone: 763-572-5710
  • Fax: 763-571-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43372
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: