Provider Demographics
NPI:1952306276
Name:LUPO, BONNIE A (MS, FNP-C)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:A
Last Name:LUPO
Suffix:
Gender:F
Credentials:MS, FNP-C
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:LUPO BARNES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, FNP-C
Mailing Address - Street 1:1700 WALKER LAKE ONTARIO RD
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-9161
Mailing Address - Country:US
Mailing Address - Phone:585-964-7622
Mailing Address - Fax:
Practice Address - Street 1:1700 WALKER LAKE ONTARIO RD
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-9161
Practice Address - Country:US
Practice Address - Phone:585-964-7622
Practice Address - Fax:585-425-5295
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332123-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02128054Medicaid
NY02128054Medicaid
NYCC3217Medicare ID - Type UnspecifiedMEDICARE