Provider Demographics
NPI:1669470993
Name:BOMBARD, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:BOMBARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 PALISADO AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2037
Mailing Address - Country:US
Mailing Address - Phone:860-214-4513
Mailing Address - Fax:
Practice Address - Street 1:843 MAIN ST # 15
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-6020
Practice Address - Country:US
Practice Address - Phone:860-648-3001
Practice Address - Fax:860-648-3003
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP48908Medicare UPIN