Provider Demographics
NPI:1467019398
Name:GUMPERT, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GUMPERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CAMPBELL AVE SW APT 215
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1335
Mailing Address - Country:US
Mailing Address - Phone:760-468-1475
Mailing Address - Fax:
Practice Address - Street 1:BLDG 3005, SR 108
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CA
Practice Address - Zip Code:93517-9351
Practice Address - Country:US
Practice Address - Phone:760-932-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider