Provider Demographics
NPI:1942219647
Name:BONAVIA, HOLLY L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:L
Last Name:BONAVIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:1575 N RIVERCENTER DR
Practice Address - Street 2:#124
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3965
Practice Address - Country:US
Practice Address - Phone:414-283-8444
Practice Address - Fax:414-283-8450
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3124-28363A00000X
WI753-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42951300Medicaid