Healthcare Provider Details

I. General information

NPI: 1710114764
Provider Name (Legal Business Name): MARY KATHRYN JENKINS BUMGARNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARY KATHRYN JENKINS

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 BLUE RIDGE RD STE 400
RALEIGH NC
27607-6477
US

IV. Provider business mailing address

2800 BLUE RIDGE RD STE 400
RALEIGH NC
27607-6477
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-5380
  • Fax: 919-784-5605
Mailing address:
  • Phone: 919-787-5380
  • Fax: 919-784-5605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-01851
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01851
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: