Provider Demographics
NPI:1033395314
Name:BONHOTAL, JACOB MATTHEW (RN)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MATTHEW
Last Name:BONHOTAL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1873 DALTON RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:NY
Mailing Address - Zip Code:14485-9568
Mailing Address - Country:US
Mailing Address - Phone:585-624-2813
Mailing Address - Fax:
Practice Address - Street 1:1873 DALTON RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:NY
Practice Address - Zip Code:14485-9568
Practice Address - Country:US
Practice Address - Phone:585-624-2813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY585295-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse