Healthcare Provider Details

I. General information

NPI: 1295792570
Provider Name (Legal Business Name): CHARLES EDWARD BONFANTI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 08/03/2007

III. Provider practice location address

630 PASEO DEL PUEBLO SUR SUITE 150
TAOS NM
87571-6070
US

IV. Provider business mailing address

PO BOX 158 SUITE 150
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-3005
  • Fax: 575-758-7010
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-747-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number75-PA002
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: