Provider Demographics
NPI:1174302806
Name:BONZO, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BONZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CHILD ST DEPT 5000
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5000
Mailing Address - Country:US
Mailing Address - Phone:904-542-7300
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST DEPT 5000
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5000
Practice Address - Country:US
Practice Address - Phone:904-542-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN49804163W00000X
FLRN11028851367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse