Provider Demographics
NPI:1790323830
Name:ZUCKERBERG, BONNY
Entity Type:Individual
Prefix:
First Name:BONNY
Middle Name:
Last Name:ZUCKERBERG
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 1:20 MERVIN ST
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-2014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1116 NEILSON ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4720
Practice Address - Country:US
Practice Address - Phone:917-692-6864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-19
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program