Provider Demographics
NPI:1194710939
Name:BOMMERSBACH, PAUL M (CRNA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:BOMMERSBACH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E 21ST ST
Mailing Address - Street 2:PAT FINANCIAL SERV.
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1016
Mailing Address - Country:US
Mailing Address - Phone:605-322-2754
Mailing Address - Fax:605-322-2727
Practice Address - Street 1:800 E 21ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1016
Practice Address - Country:US
Practice Address - Phone:605-322-2754
Practice Address - Fax:605-322-2727
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR025403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN013K4BOOtherMN BLUE CROSS BS
IA1538736Medicaid
SD005230OtherBLUE CROSS OF SD
SD4995505OtherWELLMARK
SDR025403OtherDAKOTACARE
NE46022474348Medicaid
SD5751466Medicaid
SD5751464Medicaid
MN350443300Medicaid
IA2538736Medicaid
MN350443300Medicaid
P00176112Medicare PIN
IA1538736Medicaid
IA2538736Medicaid
SDS41797Medicare PIN