Basic Information
| Provider Information | |||||||||
| NPI: | 1437475753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONGIORNO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BEATTY | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3798 E LASS AVE | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404876475 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1741 SYCAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN.135636-M-IV | OH | N | Nursing Service Providers | Licensed Practical Nurse | 363LP0808X | 0027525 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | AP246670 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.