Provider Demographics
NPI:1740751841
Name:GUM, EDWARD GARY (MSN, RN)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:GARY
Last Name:GUM
Suffix:
Gender:M
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#3 CEDAR ROAD
Mailing Address - Street 2:PO BOX 4339
Mailing Address - City:SAN FELIPE PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87001
Mailing Address - Country:US
Mailing Address - Phone:505-771-9941
Mailing Address - Fax:505-771-9992
Practice Address - Street 1:#3 CEDAR ROAD
Practice Address - Street 2:
Practice Address - City:SAN FELIPE PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87001
Practice Address - Country:US
Practice Address - Phone:505-771-9941
Practice Address - Fax:505-771-9992
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR25665163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator