Provider Demographics
NPI:1023466109
Name:BONURA, KYLE (PA-C)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:BONURA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-785-4404
Mailing Address - Fax:203-785-4580
Practice Address - Street 1:1 RESERVOIR OFFICE PARK STE 110
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3926
Practice Address - Country:US
Practice Address - Phone:203-262-9979
Practice Address - Fax:203-262-9917
Is Sole Proprietor?:No
Enumeration Date:2016-05-30
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant