Provider Demographics
NPI:1528599867
Name:BONIFACIO, MARK GERALD M (NP)
Entity Type:Individual
Prefix:
First Name:MARK GERALD
Middle Name:M
Last Name:BONIFACIO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 PECK RD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-2434
Mailing Address - Country:US
Mailing Address - Phone:626-350-2196
Mailing Address - Fax:
Practice Address - Street 1:2727 PECK RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-2434
Practice Address - Country:US
Practice Address - Phone:626-350-2196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006060363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics