Provider Demographics
NPI:1568990760
Name:BUMGARNER, ANDREW JACOB (ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JACOB
Last Name:BUMGARNER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 CHARLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3623
Mailing Address - Country:US
Mailing Address - Phone:937-631-2464
Mailing Address - Fax:
Practice Address - Street 1:1 JOHN MARSHALL DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25755-0002
Practice Address - Country:US
Practice Address - Phone:304-696-2639
Practice Address - Fax:304-696-3657
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0014342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer