Provider Demographics
NPI:1477546950
Name:WINGATE, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:WINGATE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:145 HOSPITAL AVE
Mailing Address - Street 2:SUITE 313
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1462
Mailing Address - Country:US
Mailing Address - Phone:814-375-4000
Mailing Address - Fax:814-375-4011
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-375-6560
Practice Address - Fax:814-372-2848
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD446948208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100887161Medicaid
NY02458299Medicaid
PA249178Medicare PIN
PA100887161Medicaid