Basic Information
| Provider Information | |||||||||
| NPI: | 1568535540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUMBS-PHILLIPS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | RPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 592 ROCKAWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112125539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183455000 | ||||||||
| FaxNumber: | 7183455794 | ||||||||
| Practice Location | |||||||||
| Address1: | 592 ROCKAWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183455000 | ||||||||
| FaxNumber: | 7183466747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 003026 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 01415943 | 05 | NY | MEDICAID |