Provider Demographics
NPI:1336730084
Name:BOMAR, TODD RYAN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:RYAN
Last Name:BOMAR
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:RYAN
Other - Last Name:INFINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:
Practice Address - Street 1:1570 WAVERLY RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2523
Practice Address - Country:US
Practice Address - Phone:423-224-1300
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011297363LP0808X
TN29138363LP0808X
VA0024182774363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health