Provider Demographics
NPI:1447359229
Name:BUMGARDNER, JOHN PAUL (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:BUMGARDNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 BAKER ST
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-3806
Mailing Address - Country:US
Mailing Address - Phone:601-467-3442
Mailing Address - Fax:256-350-7757
Practice Address - Street 1:1145 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-9740
Practice Address - Country:US
Practice Address - Phone:601-544-0500
Practice Address - Fax:601-544-0505
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3992174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist