Basic Information
| Provider Information | |||||||||
| NPI: | 1992209290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONNER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72 E CONCORD ST | ||||||||
| Address2: | EVANS 124 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176386500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 72 E.NEWTON STREET | ||||||||
| Address2: | STE 124 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176387253 | ||||||||
| FaxNumber: | 6176386501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 286918 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 309243 | NC | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.