Provider Demographics
NPI:1043630049
Name:WINGO, MELISSA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:WINGO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:L
Other - Last Name:SMITHSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1503 WATKINS LN UNIT 208
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-7248
Mailing Address - Country:US
Mailing Address - Phone:847-691-8553
Mailing Address - Fax:
Practice Address - Street 1:3010 HIGHLAND PKWY STE 550
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5500
Practice Address - Country:US
Practice Address - Phone:630-724-1100
Practice Address - Fax:630-724-0084
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant