Provider Demographics
NPI:1336514009
Name:BOMAN, MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOMAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 SE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2399
Mailing Address - Country:US
Mailing Address - Phone:727-954-0125
Mailing Address - Fax:
Practice Address - Street 1:1807 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2399
Practice Address - Country:US
Practice Address - Phone:727-954-0125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FLPT311702251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports