Basic Information
| Provider Information | |||||||||
| NPI: | 1801567110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONFILIO | ||||||||
| FirstName: | KINSLEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4509 E PARKCENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837164742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065461566 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 N CURTIS RD STE 303 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083774000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2021 | ||||||||
| LastUpdateDate: | 09/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-2094 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.