Provider Demographics
NPI:1598932683
Name:BUMGARNER, TINA JEAN (ANP C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:JEAN
Last Name:BUMGARNER
Suffix:
Gender:F
Credentials:ANP C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:BRUNELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-C
Mailing Address - Street 1:4654 LONG BEACH RD SE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-8799
Mailing Address - Country:US
Mailing Address - Phone:104-570-0709
Mailing Address - Fax:910-320-8449
Practice Address - Street 1:4654 LONG BEACH RD SE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-8799
Practice Address - Country:US
Practice Address - Phone:104-570-0709
Practice Address - Fax:910-320-8449
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5003968363L00000X
NC161737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCF599BOtherMEDICARE PTAN
NC7902054Medicaid