Provider Demographics
NPI:1093755175
Name:BOMAR, CATHERINE R (CPNP)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:R
Last Name:BOMAR
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:RENEE
Other - Last Name:BOMAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1100 LAKE HEARN DRIVE
Mailing Address - Street 2:STE 450
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-252-7339
Mailing Address - Fax:404-257-0337
Practice Address - Street 1:1100 LAKE HEARN DRIVE
Practice Address - Street 2:STE 450
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-252-7339
Practice Address - Fax:404-257-0337
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR077495363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000487099AMedicaid