Provider Demographics
NPI:1184938292
Name:BUMGARDNER, BRYAN MICHAEL (LPN)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:MICHAEL
Last Name:BUMGARDNER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 CHICKEN COOP RD
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:43155-9725
Mailing Address - Country:US
Mailing Address - Phone:740-746-8415
Mailing Address - Fax:
Practice Address - Street 1:4250 CHICKEN COOP RD
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:OH
Practice Address - Zip Code:43155-9725
Practice Address - Country:US
Practice Address - Phone:740-746-8415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.118223M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse