Provider Demographics
NPI:1366153215
Name:BUMPERS, WILLARD EARL
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:EARL
Last Name:BUMPERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 CAMILLA RD
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-8110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1812 CAMILLA RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-8110
Practice Address - Country:US
Practice Address - Phone:910-382-7811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman