Healthcare Provider Details

I. General information

NPI: 1770051294
Provider Name (Legal Business Name): PAMELA C MUMBA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 THOMAS JOHNSON DR
FREDERICK MD
21702-4679
US

IV. Provider business mailing address

400 W 7TH ST
FREDERICK MD
21701-4506
US

V. Phone/Fax

Practice location:
  • Phone: 240-215-6310
  • Fax:
Mailing address:
  • Phone: 240-439-8812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC08100
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA7177
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: