Provider Demographics
NPI:1245540731
Name:BONAVOGLIA, MARIE SUSAN (PA-C)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:SUSAN
Last Name:BONAVOGLIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:SUSAN
Other - Last Name:GILLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:3 W OLIVE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2572
Practice Address - Country:US
Practice Address - Phone:570-207-4054
Practice Address - Fax:570-207-4057
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052473363AM0700X
PAOA002570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical