Provider Demographics
NPI:1699082206
Name:BONGIOVANNI, KATHRYN E (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:E
Last Name:BONGIOVANNI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LAKEVILLE BUSINESS PARK
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1234
Mailing Address - Country:US
Mailing Address - Phone:508-946-6895
Mailing Address - Fax:508-946-1494
Practice Address - Street 1:2014 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1607
Practice Address - Country:US
Practice Address - Phone:617-243-6040
Practice Address - Fax:617-243-6924
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant