Basic Information
| Provider Information | |||||||||
| NPI: | 1427049121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUM | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | Z | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5130 SOUTHPORT SUPPLY RD SE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284619261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102694053 | ||||||||
| FaxNumber: | 9103634905 | ||||||||
| Practice Location | |||||||||
| Address1: | 5130 SOUTHPORT SUPPLY RD SE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284619261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102694053 | ||||||||
| FaxNumber: | 9103634905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 301 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 0010-06084 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.