Provider Demographics
NPI:1124248588
Name:BUYUM, BONNIE IRIS (PTA)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:IRIS
Last Name:BUYUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S EASTON RD
Mailing Address - Street 2:APT B406
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-3927
Mailing Address - Country:US
Mailing Address - Phone:215-886-8098
Mailing Address - Fax:
Practice Address - Street 1:905 PENLLYN PIKE
Practice Address - Street 2:
Practice Address - City:SPRING HOUSE
Practice Address - State:PA
Practice Address - Zip Code:19477
Practice Address - Country:US
Practice Address - Phone:215-646-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE005792L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant