Provider Demographics
NPI:1508109349
Name:BOMALASKI, MARTIN NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:NICHOLAS
Last Name:BOMALASKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 NE MOTHER JOSEPH PL STE 100
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3292
Practice Address - Country:US
Practice Address - Phone:360-514-3142
Practice Address - Fax:360-514-6809
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD189020208100000X
WAMD60739177208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1508109349Medicaid
WA8967115OtherMEDICARE PIN