Provider Demographics
NPI:1285358135
Name:BONAGURA, ROSE MARIE (PAC)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:BONAGURA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ROUTE 73 N STE 320
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3426
Mailing Address - Country:US
Mailing Address - Phone:856-854-0300
Mailing Address - Fax:
Practice Address - Street 1:201 HADDON AVE
Practice Address - Street 2:
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08108-2860
Practice Address - Country:US
Practice Address - Phone:856-854-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00739600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant