Healthcare Provider Details

I. General information

NPI: 1124367255
Provider Name (Legal Business Name): UMA GOPAKUMAR NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5252 E MAIN ST
MESA AZ
85205-8022
US

IV. Provider business mailing address

743 W GARY AVE
GILBERT AZ
85233-2067
US

V. Phone/Fax

Practice location:
  • Phone: 480-396-3222
  • Fax: 480-396-2298
Mailing address:
  • Phone: 480-668-5086
  • Fax: 480-396-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTAP4859
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: