Basic Information
| Provider Information | |||||||||
| NPI: | 1194710939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOMMERSBACH | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E 21ST ST | ||||||||
| Address2: | PAT FINANCIAL SERV. | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053222754 | ||||||||
| FaxNumber: | 6053222727 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E 21ST ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053222754 | ||||||||
| FaxNumber: | 6053222727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 08/20/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R025403 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 013K4BO | 01 | MN | MN BLUE CROSS BS | OTHER | 1538736 | 05 | IA | MEDICAID | 005230 | 01 | SD | BLUE CROSS OF SD | OTHER | 4995505 | 01 | SD | WELLMARK | OTHER | R025403 | 01 | SD | DAKOTACARE | OTHER | 46022474348 | 05 | NE | MEDICAID | 5751466 | 05 | SD | MEDICAID | 5751464 | 05 | SD | MEDICAID | 350443300 | 05 | MN | MEDICAID | 2538736 | 05 | IA | MEDICAID |