Provider Demographics
NPI:1043582406
Name:AGUILERA, BONIFACIO TAN (MD)
Entity Type:Individual
Prefix:
First Name:BONIFACIO
Middle Name:TAN
Last Name:AGUILERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 TERLYN DRIVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904
Mailing Address - Country:US
Mailing Address - Phone:814-467-6378
Mailing Address - Fax:
Practice Address - Street 1:307 TERLYN DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904
Practice Address - Country:US
Practice Address - Phone:814-467-6378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA17585E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine