Healthcare Provider Details

I. General information

NPI: 1760569958
Provider Name (Legal Business Name): XIMENA ELIZABETH GUMPEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RADIATION ONCOLOGY 4005 ORCHARD DRIVE
MIDLAND MI
48670-0001
US

IV. Provider business mailing address

RADIATION ONCOLOGY 4005 ORCHARD DRIVE
MIDLAND MI
48670-0001
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-3450
  • Fax: 989-839-1347
Mailing address:
  • Phone: 989-839-3450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085003014
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04049
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601005756
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: