Provider Demographics
NPI:1972350122
Name:BONOMO, VICTORIA BRIANA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:BRIANA
Last Name:BONOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 ECUSTA RD
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-5090
Mailing Address - Country:US
Mailing Address - Phone:828-243-7625
Mailing Address - Fax:
Practice Address - Street 1:490 ECUSTA RD
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-5090
Practice Address - Country:US
Practice Address - Phone:828-243-7625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant