Provider Demographics
NPI:1982802104
Name:BOMER, SHAUNA WEISE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAUNA
Middle Name:WEISE
Last Name:BOMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHAUNA
Other - Middle Name:LYNN
Other - Last Name:WEISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:785 5TH AVENUE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-217-4217
Practice Address - Street 1:112 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1720
Practice Address - Country:US
Practice Address - Phone:717-267-3000
Practice Address - Fax:717-267-7414
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT191747207L00000X
PAMD442209207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA050514OtherMEDICARE GROUP #