St. Bonaventure University

Primary specialty

Orthopaedic Surgery PhysicianTaxonomy code 207X00000X

License

211943-2 Issued in NY

Legal business name

ST. BONAVENTURE UNIVERSITY

Doing business as

St. Bonaventure Sports Medicine

Practice address

3261 W State Rd
Saint Bonaventure, NY 14778-9800

Phone

(972) 367-4845

NPI assigned

Jun 20, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mouzon Bass III

Title

Agent

Phone

(972) 367-4845

Specialties & licenses 1

Addresses

Other names 1

• St. Bonaventure Sports Medicine Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1497916800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1497916800000",
    "number": "1710407945",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5050 SPRING VALLEY RD",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752443995",
            "telephone_number": "972-367-4845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3261 W STATE RD",
            "city": "SAINT BONAVENTURE",
            "state": "NY",
            "postal_code": "147789800",
            "telephone_number": "972-367-4845"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. BONAVENTURE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-20",
        "last_updated": "2017-06-20",
        "status": "A",
        "authorized_official_last_name": "BASS",
        "authorized_official_first_name": "MOUZON",
        "authorized_official_title_or_position": "AGENT",
        "authorized_official_telephone_number": "972-367-4845",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery",
            "state": "NY",
            "license": "211943-2",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Bonaventure Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Diana V. Nguyen, PA-C
• Jennifer Nguyen
• Francesca Parry, NP
• Jesus R Perez Jr., PA-C
• Matt Smith, LAT, ATC
• Carley Fern Stevenson
• Gianna Marie Trillo
• Nicole Elise Tschiderer
• Diane Vu

• Orthopaedic Surgery Physician in Saint Bonaventure, NY
• Providers in Saint Bonaventure, NY by specialty
• Orthopaedic Surgery Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.