Healthcare Provider Details

I. General information

NPI: 1861894958
Provider Name (Legal Business Name): JOSHUA BUMGARDNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 WASHINGTON VILLAGE DR STE 210
CENTERVILLE OH
45459-4094
US

IV. Provider business mailing address

7700 WASHINGTON VILLAGE DR STE 210
CENTERVILLE OH
45459-4094
US

V. Phone/Fax

Practice location:
  • Phone: 937-562-2291
  • Fax: 937-562-2293
Mailing address:
  • Phone: 937-562-2291
  • Fax: 937-562-2293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004139
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: