Healthcare Provider Details

I. General information

NPI: 1891344735
Provider Name (Legal Business Name): EDWARD JOSEPH BONFIGLIO JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PALISADES DR STE 100
ALBANY NY
12205-6433
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-438-4496
  • Fax: 518-438-5803
Mailing address:
  • Phone: 185-255-6345
  • Fax: 518-649-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010992
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: