Provider Demographics
NPI:1629791124
Name:BONURA, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BONURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 BAYPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1418
Mailing Address - Country:US
Mailing Address - Phone:631-885-2054
Mailing Address - Fax:
Practice Address - Street 1:6277 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2837
Practice Address - Country:US
Practice Address - Phone:631-462-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310922363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health