Basic Information
| Provider Information | |||||||||
| NPI: | 1750796793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUMGARDNER | ||||||||
| FirstName: | VERONIKA | ||||||||
| MiddleName: | SAFRONOVNA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 21975 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403214281 | ||||||||
| FaxNumber: | 5403214282 | ||||||||
| Practice Location | |||||||||
| Address1: | 7915 LAKE MANASSAS DR | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201553258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712613529 | ||||||||
| FaxNumber: | 7037535613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2014 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110004522 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1750796793 | 01 | VA | MEDICARE | OTHER | 17507967793 | 05 | VA | MEDICAID |