Provider Demographics
NPI:1568535540
Name:GUMBS-PHILLIPS, SANDRA ANN (RPA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANN
Last Name:GUMBS-PHILLIPS
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 ROCKAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-5539
Mailing Address - Country:US
Mailing Address - Phone:718-345-5000
Mailing Address - Fax:718-345-5794
Practice Address - Street 1:592 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212
Practice Address - Country:US
Practice Address - Phone:718-345-5000
Practice Address - Fax:718-346-6747
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003026363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01415943Medicaid