Provider Demographics
NPI:1134726433
Name:BONFIGLIO, JASON (PA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BONFIGLIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BISHOPS WAY UNIT 629
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6261
Mailing Address - Country:US
Mailing Address - Phone:414-588-3405
Mailing Address - Fax:
Practice Address - Street 1:800 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1943
Practice Address - Country:US
Practice Address - Phone:715-258-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100135023Medicaid