Provider Demographics
NPI:1760812895
Name:BONANNI, STEPHEN JR (PA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:BONANNI
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2570
Mailing Address - Country:US
Mailing Address - Phone:912-785-2100
Mailing Address - Fax:
Practice Address - Street 1:508 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2570
Practice Address - Country:US
Practice Address - Phone:912-785-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2025-05-11
Deactivation Date:2025-03-25
Deactivation Code:
Reactivation Date:2025-05-09
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA12279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant