Healthcare Provider Details

I. General information

NPI: 1619580933
Provider Name (Legal Business Name): DYLAN GUMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/26/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1538 CHARLESTON AVE
HUNTINGTON WV
25701
US

IV. Provider business mailing address

1538 CHARLESTON AVE
HUNTINGTON WV
25701
US

V. Phone/Fax

Practice location:
  • Phone: 304-696-7302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: