Provider Demographics
NPI:1396805479
Name:BUONAVITA, GRACE A (PAC)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:BUONAVITA
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 1:436 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-6523
Mailing Address - Country:US
Mailing Address - Phone:909-877-8868
Mailing Address - Fax:909-877-0008
Practice Address - Street 1:436 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-6523
Practice Address - Country:US
Practice Address - Phone:909-877-8868
Practice Address - Fax:909-877-0008
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA13592OtherMEDICAL LICENSE
PA13592OtherMEDICAL LICENSE