Provider Demographics
NPI:1578562526
Name:BONILLA, MELISSA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 KINGS HWY E STE 106
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-4871
Mailing Address - Country:US
Mailing Address - Phone:203-819-1203
Mailing Address - Fax:203-819-1203
Practice Address - Street 1:501 KINGS HWY E STE 106
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-4871
Practice Address - Country:US
Practice Address - Phone:203-819-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001589363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001589OtherSTATE LICENSE