Provider Demographics
NPI:1598301632
Name:BLOOM, DANIEL EDWARD (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:EDWARD
Last Name:BLOOM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL HOSPITAL PENSACOLA 6000 WEST HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32512-0003
Mailing Address - Country:US
Mailing Address - Phone:850-505-6601
Mailing Address - Fax:
Practice Address - Street 1:NAVAL BRANCH HEALTH CLINIC GULFPORT
Practice Address - Street 2:5502 MARVIN SHIELDS BLVD
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-871-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1165862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant