Provider Demographics
NPI:1912177809
Name:BUMGARNER, SHELLY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:BUMGARNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W MARTINTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3194
Mailing Address - Country:US
Mailing Address - Phone:803-441-0025
Mailing Address - Fax:
Practice Address - Street 1:401 W MARTINTOWN RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3194
Practice Address - Country:US
Practice Address - Phone:803-441-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC558225200000X
GAPTA002163225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC558OtherSC LICNESE