Healthcare Provider Details

I. General information

NPI: 1063838241
Provider Name (Legal Business Name): AMY BUMGARNER PT, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4633 BRAMBLETON AVE #202
ROANOKE VA
24018-3410
US

IV. Provider business mailing address

4633 BRAMBLETON AVE #202
ROANOKE VA
24018-3410
US

V. Phone/Fax

Practice location:
  • Phone: 540-774-0729
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305207650
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: