MEDICARE: MR. RYAN LEE BUMPAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1326284936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN LEE BUMPAS

Provider Business Mailing Address
First Line	:	3523 DOROTHY LN S
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-1731
Country	:	US
Telephone Number	:	817-763-8360
Fax Number	:

Provider Business Practice Location Address
First Line	:	3523 DOROTHY LN S
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-1731
Country	:	US
Telephone Number	:	817-763-8360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2009
Last Update Date	:	01/02/2009

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