Provider Demographics
NPI:1942865548
Name:BONNER, MILES KIERNAN
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:KIERNAN
Last Name:BONNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MORGAN HWY STE 4
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2641
Mailing Address - Country:US
Mailing Address - Phone:570-344-3788
Mailing Address - Fax:
Practice Address - Street 1:5325 NORTHGATE DR STE 209
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-9416
Practice Address - Country:US
Practice Address - Phone:610-954-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS023112208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation