=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679980056
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN GUMPERT MS ED ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2014
-----------------------------------------------------
Last Update Date | 07/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 N GRAND AVE SUITE 6A
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75090-4440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-813-2499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 N HARRISON AVE
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75090-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-554-6311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT4138
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------