Healthcare Provider Details

I. General information

NPI: 1467019398
Provider Name (Legal Business Name): MICHAEL GUMPERT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2019
Last Update Date: 02/14/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 3005, SR 108
BRIDGEPORT CA
93517-9351
US

IV. Provider business mailing address

35 CAMPBELL AVE SW APT 215
ROANOKE VA
24011-1335
US

V. Phone/Fax

Practice location:
  • Phone: 760-932-1616
  • Fax:
Mailing address:
  • Phone: 760-468-1475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: