Healthcare Provider Details

I. General information

NPI: 1578819405
Provider Name (Legal Business Name): MONICA M BOMAR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 456
BALD KNOB AR
72010-0456
US

IV. Provider business mailing address

117 S 2ND ST
AUGUSTA AR
72006-2309
US

V. Phone/Fax

Practice location:
  • Phone: 501-724-6207
  • Fax: 501-724-3305
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-347-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberP-T1224
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-484
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: