Healthcare Provider Details

I. General information

NPI: 1053830265
Provider Name (Legal Business Name): LAUREN ELIZABETH GUMP PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

2638 21ST ST APT 12E
ASTORIA NY
11102-4204
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-5454
  • Fax:
Mailing address:
  • Phone: 774-573-2144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: