Healthcare Provider Details

I. General information

NPI: 1992074496
Provider Name (Legal Business Name): LEAH MARIE GUMUCIO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 JENNINGS MILL RD STE 290A
WATKINSVILLE GA
30677-7238
US

IV. Provider business mailing address

4500 FOREST DR STE A
COLUMBIA SC
29206-3105
US

V. Phone/Fax

Practice location:
  • Phone: 706-552-1840
  • Fax: 706-552-1849
Mailing address:
  • Phone: 803-738-9522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number007513
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: