Provider Demographics
NPI:1245244516
Name:BOMMERSBACH, ALICIA R (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:R
Last Name:BOMMERSBACH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:6255 SHERIDAN DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4836
Mailing Address - Country:US
Mailing Address - Phone:716-857-8666
Mailing Address - Fax:716-857-8944
Practice Address - Street 1:295 ESSJAY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8216
Practice Address - Country:US
Practice Address - Phone:716-630-1022
Practice Address - Fax:716-250-5958
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY011319363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000528705001OtherHEALTH NOW
NY9513979OtherINDEPENDENT HEALTH
NY00027739701OtherUNIVERA
NY02808822Medicaid
NY9513979OtherINDEPENDENT HEALTH