Provider Demographics
NPI:1063880573
Name:BONAVENTURA, RONALD AUGUST JR
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:AUGUST
Last Name:BONAVENTURA
Suffix:JR
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 1:22432 HARPER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-4041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22432 HARPER LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-4041
Practice Address - Country:US
Practice Address - Phone:586-557-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily