Provider Demographics
NPI:1174282099
Name:MATHEW, BONY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BONY
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 S THORNHILL RD APT 1
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-2725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:558 S PASEO DOROTEA STE 6
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-1429
Practice Address - Country:US
Practice Address - Phone:760-423-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023999363L00000X
CA95022391363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner