Provider Demographics
NPI:1962765883
Name:BONANNO, ADAM V (MSED)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:V
Last Name:BONANNO
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CRANBERRY CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1987
Mailing Address - Country:US
Mailing Address - Phone:718-702-5471
Mailing Address - Fax:
Practice Address - Street 1:1535 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1520
Practice Address - Country:US
Practice Address - Phone:718-556-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1093188174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist