Healthcare Provider Details

I. General information

NPI: 1710986419
Provider Name (Legal Business Name): THOMAS CHARLES BLOOMQUIST CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MILES ST
DAMARISCOTTA ME
04543-4047
US

IV. Provider business mailing address

35 MILES ST
DAMARISCOTTA ME
04543-4047
US

V. Phone/Fax

Practice location:
  • Phone: 207-563-4146
  • Fax: 207-563-3717
Mailing address:
  • Phone: 207-563-4146
  • Fax: 207-563-3717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number048605-23-11
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA83341
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: