MEDICARE: CARL JOSEPH BONANNO

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
1	225200000X	Physical Therapy Assistant		AZ

General Provider Information

NPI Number	:	1952068306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARL JOSEPH BONANNO

Provider Business Mailing Address
First Line	:	10714 W WELK DR
Second Line	:
City	:	SUN CITY
State	:	AZ
Zip	:	85373-1841
Country	:	US
Telephone Number	:	623-330-3502
Fax Number	:

Provider Business Practice Location Address
First Line	:	11301 N 99TH AVE
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-5466
Country	:	US
Telephone Number	:	623-977-9373
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2021
Last Update Date	:	11/19/2021

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Directions to “ CARL JOSEPH BONANNO ” Practice Location

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