Healthcare Provider Details

I. General information

NPI: 1235892258
Provider Name (Legal Business Name): MICHELLE L BOMGARDNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2021
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 DEMERS AVE
GRAND FORKS ND
58201-4040
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-746-7521
  • Fax:
Mailing address:
  • Phone: 605-328-9419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC1152
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: