Provider Demographics
NPI:1366538050
Name:GUMM, EDWARD L (PA-C)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:GUMM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BOB O LINK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504
Mailing Address - Country:US
Mailing Address - Phone:859-258-8575
Mailing Address - Fax:859-258-8562
Practice Address - Street 1:700 BOB O LINK DRIVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:US
Practice Address - Phone:859-258-8575
Practice Address - Fax:859-258-8562
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA274363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCB5773OtherRR MEDICARE GROUP
KY4000501OtherMEDICARE LAB GROUP
KY95001277Medicaid
KY36000818OtherASC MEDICAID GROUP
KYASC1019OtherASC MEDICARE GROUP
KY37903705OtherMEDICAID LAB GROUP
KY0624120Medicare ID - Type Unspecified
KY4000501OtherMEDICARE LAB GROUP