Provider Demographics
NPI:1215023114
Name:BOMALASKI, PATRICIA M (CRNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:BOMALASKI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:S
Other - Last Name:BOMALASKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:51 N. 39TH STREET
Mailing Address - Street 2:MAB, SUITE 102
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-9990
Mailing Address - Fax:215-243-3297
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:MAB, SUITE 102
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-9990
Practice Address - Fax:215-243-3297
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP005247C363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA087984Medicare PIN