Provider Demographics
NPI:1710134408
Name:BLOOMFIELD, ELIZABETH M (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:BLOOMFIELD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:HULSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-2900
Mailing Address - Fax:817-735-2902
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-2900
Practice Address - Fax:817-735-2902
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA605363A00000X
TXPA02115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00680238OtherRAILROAD MEDICARE
TX196967701Medicaid
TX8Y8715OtherBCBS
TX196967701Medicaid