Healthcare Provider Details

I. General information

NPI: 1750796793
Provider Name (Legal Business Name): VERONIKA SAFRONOVNA BUMGARDNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2014
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7915 LAKE MANASSAS DR SUITE 205
GAINESVILLE VA
20155-3258
US

IV. Provider business mailing address

PO BOX 21975
BELFAST ME
04915-4116
US

V. Phone/Fax

Practice location:
  • Phone: 571-261-3529
  • Fax: 703-753-5613
Mailing address:
  • Phone: 540-321-4281
  • Fax: 540-321-4282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004522
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: