Healthcare Provider Details

I. General information

NPI: 1619928199
Provider Name (Legal Business Name): BRUCE A. BOLONESI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5131 COTTONWOOD ST # L-2
MURRAY UT
84107-5701
US

IV. Provider business mailing address

1121 E 3900 S SUITE C-240
SALT LAKE CITY UT
84124-1214
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-3416
  • Fax:
Mailing address:
  • Phone: 801-263-3416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number106591-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: