Provider Demographics
NPI:1629832126
Name:BONILLA, VINCENT
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 7TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5766
Mailing Address - Country:US
Mailing Address - Phone:516-747-7778
Mailing Address - Fax:
Practice Address - Street 1:229 7TH ST STE 105
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5766
Practice Address - Country:US
Practice Address - Phone:516-747-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant