Provider Demographics
NPI:1619220019
Name:BONIN, MARK DANIEL (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:BONIN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 S PRUDENCE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-3415
Mailing Address - Country:US
Mailing Address - Phone:507-210-4322
Mailing Address - Fax:
Practice Address - Street 1:2800 E AJO WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6204
Practice Address - Country:US
Practice Address - Phone:520-874-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP4719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily