Provider Demographics
NPI:1568970044
Name:GUMBS, SHAWN RAPHAEL
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:RAPHAEL
Last Name:GUMBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23502 118TH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11411-1816
Mailing Address - Country:US
Mailing Address - Phone:347-385-9028
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:347-385-9028
Practice Address - Fax:718-528-0611
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY584827-1163W00000X
NY121631367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse