MEDICARE: PAULA MICHELLE HOMBERGER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1695	CO

General Provider Information

NPI Number	:	1053517805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULA MICHELLE HOMBERGER PA-C

Provider Business Mailing Address
First Line	:	1230 BECKY DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-2207
Country	:	US
Telephone Number	:	719-559-2305
Fax Number	:

Provider Business Practice Location Address
First Line	:	1495 GARDEN OF THE GODS RD
Second Line	:	SUITE 102
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-9441
Country	:	US
Telephone Number	:	719-260-9797
Fax Number	:	719-260-9799

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	07/30/2012

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