Healthcare Provider Details

I. General information

NPI: 1548707854
Provider Name (Legal Business Name): CECILLE GUMABON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST UNIVERSITY OF MARYLAND MEDICAL CENTER - DEPT OF MED
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

22 SOUTH GREENE STREET UNIVERSITY OF MD MEDICAL CENTER, N13W46
BALTIMORE MD
21201
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006351
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: