Provider Demographics
NPI:1588811442
Name:BONILLA, VALENTIN JR (PA)
Entity Type:Individual
Prefix:MR
First Name:VALENTIN
Middle Name:
Last Name:BONILLA
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:23B COOPER PL
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-2805
Mailing Address - Country:US
Mailing Address - Phone:917-856-6274
Mailing Address - Fax:212-256-2609
Practice Address - Street 1:160 WATER ST
Practice Address - Street 2:2420
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4922
Practice Address - Country:US
Practice Address - Phone:212-256-2602
Practice Address - Fax:212-256-2609
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000569-1363AM0700X
NY000569363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02994489Medicaid