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NPI Code Detail

MEDICARE: JOHN RYAN BONAOBRA

MEDICARE: JOHN RYAN BONAOBRA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183700000XPharmacy Technician26021OK

General Provider Information

NPI Number : 1578156220
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN RYAN BONAOBRA
Provider Business Mailing Address
First Line : 1770 S ELM PL
Second Line :
City : BROKEN ARROW
State : OK
Zip : 74012-6453
Country : US
Telephone Number : 918-258-6185
Fax Number :
Provider Business Practice Location Address
First Line : 1770 S ELM PL
Second Line :
City : BROKEN ARROW
State : OK
Zip : 74012-6453
Country : US
Telephone Number : 918-258-6185
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/13/2021
Last Update Date : 02/13/2021

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