Provider Demographics
NPI:1619646411
Name:BONO, SAMANTHA LOUISE (PAC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LOUISE
Last Name:BONO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CLOVER HILL LN
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-1004
Mailing Address - Country:US
Mailing Address - Phone:908-839-5638
Mailing Address - Fax:
Practice Address - Street 1:1200 EAGLE AVE
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-7631
Practice Address - Country:US
Practice Address - Phone:732-660-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00639500363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty