Basic Information
| Provider Information | |||||||||
| NPI: | 1336424530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONO | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 494910 | ||||||||
| Address2: | COASTAL DERMATOLOGY | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339494910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416132400 | ||||||||
| FaxNumber: | 9416132401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1617 TAMIAMI TRL | ||||||||
| Address2: | COASTAL DERMATOLOGY | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339481040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416132400 | ||||||||
| FaxNumber: | 9416132401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2011 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106237 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | FN731Z | 01 | FL | MEDICARE | OTHER |