Provider Demographics
NPI:1437475753
Name:BONGIORNO, MICHAEL P (NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:BONGIORNO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3798 E LASS AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0817
Mailing Address - Country:US
Mailing Address - Phone:440-487-6475
Mailing Address - Fax:
Practice Address - Street 1:1741 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0927
Practice Address - Country:US
Practice Address - Phone:928-757-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.135636-M-IV164W00000X
OH0027525363LP0808X
AZAP246670363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse