Provider Demographics
NPI:1174538052
Name:BLOOM, MARCENE A (PA)
Entity type:Individual
Prefix:
First Name:MARCENE
Middle Name:A
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7316
Mailing Address - Country:US
Mailing Address - Phone:605-341-7337
Mailing Address - Fax:605-341-2447
Practice Address - Street 1:2905 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7316
Practice Address - Country:US
Practice Address - Phone:605-341-7337
Practice Address - Fax:605-341-2447
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6823440Medicaid
SD0479OtherSTATE LICENSE