Provider Demographics
NPI:1972743748
Name:LA BOMBARDA, NICOLE ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:LA BOMBARDA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-1550
Mailing Address - Country:US
Mailing Address - Phone:907-443-3504
Mailing Address - Fax:
Practice Address - Street 1:1000 GREG KRUSCHEK AVENUE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-443-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD130061000Medicaid