Healthcare Provider Details

I. General information

NPI: 1568990760
Provider Name (Legal Business Name): ANDREW JACOB BUMGARNER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JOHN MARSHALL DR
HUNTINGTON WV
25755-0002
US

IV. Provider business mailing address

1225 CHARLESTON AVE
HUNTINGTON WV
25701-3623
US

V. Phone/Fax

Practice location:
  • Phone: 304-696-2639
  • Fax: 304-696-3657
Mailing address:
  • Phone: 937-631-2464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001434
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: