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General NPI Number Information
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NPI Number | 1568970044
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Entity Type | Individual
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Provider Name | SHAWN RAPHAEL GUMBS
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Gender | Male
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Dates
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Enumeration Date | 01/18/2018
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Last Update Date | 03/07/2018
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Provider Practice Location Address
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Address Line | 259 1ST ST
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City | MINEOLA
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State | NY
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Zip | 11501-3957
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Country | US
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Telephone | 347-385-9028
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Fax | 718-528-0611
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Provider Business Mailing Address
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Address Line | 23502 118TH AVE APT 2
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City | CAMBRIA HEIGHTS
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State | NY
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Zip | 11411-1816
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Country | US
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Telephone | 347-385-9028
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 584827-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 121631
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License Number State | NY
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