Basic Information
| Provider Information | |||||||||
| NPI: | 1841627353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONELLI | ||||||||
| FirstName: | BAOKIM | ||||||||
| MiddleName: | NGUYEN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 FIREMANS MEMORIAL DRIVE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007508616 | ||||||||
| FaxNumber: | 8453628474 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 SULLIVAN ST | ||||||||
| Address2: | SUITE/APT # | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100121354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123853700 | ||||||||
| FaxNumber: | 2123853703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2013 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 017064 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.