Provider Demographics
NPI:1710114764
Name:BUMGARNER, MARY KATHRYN JENKINS (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY KATHRYN
Middle Name:JENKINS
Last Name:BUMGARNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARY KATHRYN
Other - Middle Name:
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 BLUE RIDGE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6477
Mailing Address - Country:US
Mailing Address - Phone:919-787-5380
Mailing Address - Fax:919-784-5605
Practice Address - Street 1:2800 BLUE RIDGE RD STE 400
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6477
Practice Address - Country:US
Practice Address - Phone:919-787-5380
Practice Address - Fax:919-784-5605
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01851363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2762114Medicare PIN