Provider Demographics
NPI:1043382666
Name:ABOLHASSANI BLOOMER, TINA (NP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:ABOLHASSANI BLOOMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19171 JASPER HILL RD
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-1121
Mailing Address - Country:US
Mailing Address - Phone:949-633-9100
Mailing Address - Fax:
Practice Address - Street 1:4010 E CHAPMAN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3990
Practice Address - Country:US
Practice Address - Phone:714-500-0358
Practice Address - Fax:714-532-3943
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 486773363LW0102X
CANP 10584363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health