Basic Information
| Provider Information | |||||||||
| NPI: | 1750425849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOMQUIST | ||||||||
| FirstName: | SHEILA | ||||||||
| MiddleName: | EVA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E. HIGHWAY 260 | ||||||||
| Address2: | SUITE G | ||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284788905 | ||||||||
| FaxNumber: | 9284788915 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E STATE HIGHWAY 260 | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855414921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284788905 | ||||||||
| FaxNumber: | 9284788915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 10/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036112093 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 40881 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 178726 | 01 | AHCCCS # | OTHER | 178726 | 05 | AZ | MEDICAID |