Provider Demographics
NPI:1427036847
Name:BONFIGLIO, SUSAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:BONFIGLIO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5319
Mailing Address - Country:US
Mailing Address - Phone:602-200-5325
Mailing Address - Fax:602-200-5335
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-200-5325
Practice Address - Fax:602-200-5335
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO383363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97375578Medicaid
CO485268Medicare ID - Type Unspecified
CO97375578Medicaid