Provider Demographics
NPI:1275638025
Name:WINGARD, LARRY B (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:B
Last Name:WINGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL ARTS BLDG
Mailing Address - Street 2:SUITE 150
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-7135
Mailing Address - Country:US
Mailing Address - Phone:724-543-5919
Mailing Address - Fax:724-543-3544
Practice Address - Street 1:100 MEDICAL ARTS BLDG
Practice Address - Street 2:SUITE 150
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-7135
Practice Address - Country:US
Practice Address - Phone:724-543-5919
Practice Address - Fax:724-543-3544
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD015910E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB32064Medicare UPIN
PA013327Medicare ID - Type Unspecified