MEDICARE: GABRIELLE ELAINA BULLEMAN PA-C

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	208000000X	Pediatrics Physician	5955	SC

General Provider Information

NPI Number	:	1629952411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE ELAINA BULLEMAN PA-C

Provider Business Mailing Address
First Line	:	8120 ROURK ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-4127
Country	:	US
Telephone Number	:	843-449-1438
Fax Number	:

Provider Business Practice Location Address
First Line	:	8120 ROURK ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-4127
Country	:	US
Telephone Number	:	843-449-1438
Fax Number	:

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

Provider Enumeration Date	:	08/04/2025
Last Update Date	:	05/05/2026

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