Provider Demographics
NPI:1053564179
Name:BLOOM, SHARI (PA-C)
Entity type:Individual
Prefix:
First Name:SHARI
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALK LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-491-6482
Mailing Address - Fax:
Practice Address - Street 1:1665 BONANZA DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-5127
Practice Address - Country:US
Practice Address - Phone:435-649-7640
Practice Address - Fax:435-649-1365
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
UTMT0903117363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily