Provider Demographics
NPI:1245248228
Name:BONENFANT, BRIAN (PA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BONENFANT
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 1:208 MILL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5208
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:
Practice Address - Street 1:88 WASHINGTON STREET
Practice Address - Street 2:ATTN EMERGENCY DEPT
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780
Practice Address - Country:US
Practice Address - Phone:508-828-7108
Practice Address - Fax:508-828-7158
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P33038Medicare UPIN
MAAP1482Medicare ID - Type Unspecified