Provider Demographics
NPI:1598932683
Name:BUMGARNER, TINA JEAN (ANP C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:JEAN
Last Name:BUMGARNER
Suffix:
Gender:
Credentials:ANP C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:BRUNELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-C
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-579-8363
Mailing Address - Fax:910-579-8306
Practice Address - Street 1:75 EMERSON BAY RD STE 102
Practice Address - Street 2:
Practice Address - City:CAROLINA SHORES
Practice Address - State:NC
Practice Address - Zip Code:28467-2498
Practice Address - Country:US
Practice Address - Phone:910-579-8363
Practice Address - Fax:910-579-8306
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5003968363L00000X
NC161737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7902054Medicaid
NCNCF599BOtherMEDICARE PTAN