Healthcare Provider Details

I. General information

NPI: 1568970044
Provider Name (Legal Business Name): SHAWN RAPHAEL GUMBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 1ST ST
MINEOLA NY
11501-3957
US

IV. Provider business mailing address

23502 118TH AVE APT 2
CAMBRIA HEIGHTS NY
11411-1816
US

V. Phone/Fax

Practice location:
  • Phone: 347-385-9028
  • Fax: 718-528-0611
Mailing address:
  • Phone: 347-385-9028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number584827-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number121631
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: