Provider Demographics
NPI:1326357039
Name:BONNEY, TREVOR ROY JR (PAC)
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:ROY
Last Name:BONNEY
Suffix:JR
Gender:M
Credentials:PAC
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Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:9 FOUNDERS PAVILLION
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4238
Mailing Address - Country:US
Mailing Address - Phone:215-662-3999
Mailing Address - Fax:215-662-2879
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:EAST PAVILION, 2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4306
Practice Address - Country:US
Practice Address - Phone:215-615-4949
Practice Address - Fax:215-615-0829
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2022-12-09
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Provider Licenses
StateLicense IDTaxonomies
PAMA054614363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-2076152OtherGROUP TAX ID