Healthcare Provider Details

I. General information

NPI: 1679980056
Provider Name (Legal Business Name): EVAN GUMPERT MS ED ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N GRAND AVE SUITE 6A
SHERMAN TX
75090-4440
US

IV. Provider business mailing address

713 N HARRISON AVE
SHERMAN TX
75090-4211
US

V. Phone/Fax

Practice location:
  • Phone: 903-813-2499
  • Fax:
Mailing address:
  • Phone: 409-554-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT4138
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: