1477749992 NPI number — MICHELLE WINGO P.A.

Table of content: MICHELLE WINGO P.A. (NPI 1477749992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477749992 NPI number — MICHELLE WINGO P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINGO
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477749992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1533
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72403-1533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-932-1820
Provider Business Mailing Address Fax Number:
870-972-6712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 E MATTHEWS AVE
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-3144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-932-1820
Provider Business Practice Location Address Fax Number:
870-972-6712
Provider Enumeration Date:
09/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA-319 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1477749992 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: P00735097 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".