Provider Demographics
NPI:1124676770
Name:BONOTANO, RANDY PATIO
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:PATIO
Last Name:BONOTANO
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 1:109 SAN DIEGO AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-1038
Mailing Address - Country:US
Mailing Address - Phone:415-203-0749
Mailing Address - Fax:
Practice Address - Street 1:109 SAN DIEGO AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-1038
Practice Address - Country:US
Practice Address - Phone:415-203-0749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA041931939343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIT-04-19-31939Medicaid