Provider Demographics
NPI:1003880154
Name:BOMBERO, JON EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:EDWARD
Last Name:BOMBERO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 GOODLETTE RD N
Mailing Address - Street 2:STE 205
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5618
Mailing Address - Country:US
Mailing Address - Phone:239-436-3666
Mailing Address - Fax:239-436-3678
Practice Address - Street 1:730 GOODLETTE RD N
Practice Address - Street 2:STE 205
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5618
Practice Address - Country:US
Practice Address - Phone:239-436-3666
Practice Address - Fax:239-436-3678
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9103113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S43784Medicare UPIN
U4685ZMedicare ID - Type Unspecified