Provider Demographics
NPI:1063838241
Name:BUMGARNER, AMY (PT, MS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BUMGARNER
Suffix:
Gender:F
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 BRAMBLETON AVE
Mailing Address - Street 2:#202
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4633 BRAMBLETON AVE
Practice Address - Street 2:#202
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3410
Practice Address - Country:US
Practice Address - Phone:540-774-0729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist