Provider Demographics
NPI:1780676734
Name:BOUMA, BRUCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:BOUMA
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 1:235 E ROWAN AVE
Mailing Address - Street 2:204
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1240
Mailing Address - Country:US
Mailing Address - Phone:509-344-3100
Mailing Address - Fax:509-344-3104
Practice Address - Street 1:235 E ROWAN AVE
Practice Address - Street 2:204
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1240
Practice Address - Country:US
Practice Address - Phone:509-344-3100
Practice Address - Fax:509-344-3104
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2011-01-20
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
WAMD00019896174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8322109Medicaid
WA8322109Medicaid
WAA07654Medicare UPIN