Provider Demographics
NPI:1245728013
Name:BONACUSO, MICHAEL THOMAS (ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:BONACUSO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:EAST WILLISTON
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2510
Mailing Address - Country:US
Mailing Address - Phone:516-384-4354
Mailing Address - Fax:
Practice Address - Street 1:15 SHADOW LN
Practice Address - Street 2:
Practice Address - City:EAST WILLISTON
Practice Address - State:NY
Practice Address - Zip Code:11596-2510
Practice Address - Country:US
Practice Address - Phone:516-384-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer