Provider Demographics
NPI:1578819405
Name:BOMAR, MONICA M (PA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:M
Last Name:BOMAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-2309
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-5556
Practice Address - Street 1:PO BOX 456
Practice Address - Street 2:
Practice Address - City:BALD KNOB
Practice Address - State:AR
Practice Address - Zip Code:72010-0456
Practice Address - Country:US
Practice Address - Phone:501-724-6207
Practice Address - Fax:501-724-3305
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP-T1224363AM0700X
ARPA-484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193007795Medicaid
AR57297Medicare PIN
AR247362YJG2Medicare PIN