Provider Demographics
NPI:1992209290
Name:BONNER, RYAN WILLIAM
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:WILLIAM
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 1:72 E CONCORD ST
Mailing Address - Street 2:EVANS 124
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2640
Mailing Address - Country:US
Mailing Address - Phone:617-638-6500
Mailing Address - Fax:
Practice Address - Street 1:72 E.NEWTON STREET
Practice Address - Street 2:STE 124
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-7253
Practice Address - Fax:617-638-6501
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA286918207R00000X
390200000X
NC309243390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine