Provider Demographics
NPI:1801074042
Name:BLOOM, BYRON J (PA-C)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:J
Last Name:BLOOM
Suffix:
Gender:M
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 1:883 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-2607
Mailing Address - Country:US
Mailing Address - Phone:931-685-1145
Mailing Address - Fax:931-685-8014
Practice Address - Street 1:883 UNION ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2607
Practice Address - Country:US
Practice Address - Phone:931-685-1145
Practice Address - Fax:931-685-8014
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN922363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1801074042OtherNPI
TN922OtherPA LICENSE NUMBER