Provider Demographics
NPI:1790178317
Name:BONIFACE, STEPHEN KENNETH (MSN, NP, AGPCNP-BC)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:KENNETH
Last Name:BONIFACE
Suffix:
Gender:M
Credentials:MSN, NP, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 BLOSSOM HILL RD
Mailing Address - Street 2:SUITE 390B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-1652
Mailing Address - Country:US
Mailing Address - Phone:408-794-1250
Mailing Address - Fax:
Practice Address - Street 1:393 BLOSSOM HILL RD
Practice Address - Street 2:SUITE 390B
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-1652
Practice Address - Country:US
Practice Address - Phone:408-794-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002018363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology