Provider Demographics
NPI:1619928199
Name:BOLONESI, BRUCE A (PA-C)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:BOLONESI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:SUITE C-240
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1214
Mailing Address - Country:US
Mailing Address - Phone:801-263-3416
Mailing Address - Fax:
Practice Address - Street 1:5131 COTTONWOOD ST # L-2
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-263-3416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106591-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT270286OtherALTIUS
UT005717224Medicare PIN
UT270286OtherALTIUS