Healthcare Provider Details

I. General information

NPI: 1265205108
Provider Name (Legal Business Name): JASON COREY BLOOMER MSN, RN, CCRN, FANAI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

IV. Provider business mailing address

1412 PITT ST NE
ALBUQUERQUE NM
87112-4240
US

V. Phone/Fax

Practice location:
  • Phone: 575-308-3787
  • Fax: 505-843-8886
Mailing address:
  • Phone: 575-308-3787
  • Fax: 505-843-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN-80349
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN-80349
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: