Provider Demographics
NPI:1477309748
Name:BLOOM, NICOLE KRISTEN (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KRISTEN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:BLOOM
Other - Last Name:FREITAS-OSOFSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:6132 BEARCAT DR
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-9370
Mailing Address - Country:US
Mailing Address - Phone:415-827-1710
Mailing Address - Fax:
Practice Address - Street 1:6132 BEARCAT DR
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-9370
Practice Address - Country:US
Practice Address - Phone:415-827-1710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-27
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant