Provider Demographics
NPI:1245337906
Name:BONILLA, RYAN SAMUEL (MPT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:SAMUEL
Last Name:BONILLA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9873 BAYWINDS DR
Mailing Address - Street 2:UNIT 5211
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1845
Mailing Address - Country:US
Mailing Address - Phone:561-906-0607
Mailing Address - Fax:
Practice Address - Street 1:3898 VIA POINCIANA
Practice Address - Street 2:SUITE 12
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2951
Practice Address - Country:US
Practice Address - Phone:561-966-9273
Practice Address - Fax:561-966-8810
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 22295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist