Healthcare Provider Details

I. General information

NPI: 1376861690
Provider Name (Legal Business Name): MARY M BONOMO P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD KLEIN 510
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

5501 OLD YORK RD KLEIN 510
PHILADELPHIA PA
19141-3018
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-6933
  • Fax:
Mailing address:
  • Phone: 215-456-6933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA051566
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: