Provider Demographics
NPI:1578592937
Name:BOMANN, MARK DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:BOMANN
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 1:1100 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-223-6980
Mailing Address - Fax:206-223-6982
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101
Practice Address - Country:US
Practice Address - Phone:206-223-6980
Practice Address - Fax:206-223-6982
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74455207L00000X
WAMD60918910207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A744550Medicaid
00A744550Medicare ID - Type Unspecified
CA00A744550Medicaid