Provider Demographics
NPI:1477702892
Name:BONILLA, MILENA (PA-C)
Entity type:Individual
Prefix:
First Name:MILENA
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E ROUTE 59 # 408
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2905
Mailing Address - Country:US
Mailing Address - Phone:718-362-1411
Mailing Address - Fax:718-414-1651
Practice Address - Street 1:258 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-5351
Practice Address - Country:US
Practice Address - Phone:212-222-0075
Practice Address - Fax:646-829-9230
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012705363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400044095Medicare UPIN
NJ259794TCAMedicare UPIN