Provider Demographics
NPI:1750796793
Name:BUMGARDNER, VERONIKA SAFRONOVNA (PA-C)
Entity type:Individual
Prefix:MS
First Name:VERONIKA
Middle Name:SAFRONOVNA
Last Name:BUMGARDNER
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:PO BOX 21975
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4116
Mailing Address - Country:US
Mailing Address - Phone:540-321-4281
Mailing Address - Fax:540-321-4282
Practice Address - Street 1:7915 LAKE MANASSAS DR
Practice Address - Street 2:SUITE 205
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3258
Practice Address - Country:US
Practice Address - Phone:571-261-3529
Practice Address - Fax:703-753-5613
Is Sole Proprietor?:No
Enumeration Date:2014-06-29
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110004522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1750796793OtherMEDICARE
VA17507967793Medicaid