Provider Demographics
NPI:1477700235
Name:BLOOMER, HEATHER S (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:S
Last Name:BLOOMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:S
Other - Last Name:REIF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2465 N WOODRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8208
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:
Practice Address - Street 1:2465 N WOODRIDGE CT
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8208
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST02238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200569740BMedicaid
KSKA1295030Medicare PIN