Provider Demographics
NPI:1669279105
Name:BONANNO, ALYSSA (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:BONANNO
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Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:71 BORDER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1044
Mailing Address - Country:US
Mailing Address - Phone:781-890-2133
Mailing Address - Fax:781-890-2177
Practice Address - Street 1:71 BORDER RD STE 300
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1044
Practice Address - Country:US
Practice Address - Phone:781-890-2133
Practice Address - Fax:781-890-2177
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAPA101590363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant