Provider Demographics
NPI:1477749992
Name:WINGO, MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WINGO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1533
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1533
Mailing Address - Country:US
Mailing Address - Phone:870-932-1820
Mailing Address - Fax:870-972-6712
Practice Address - Street 1:505 E MATTHEWS AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3144
Practice Address - Country:US
Practice Address - Phone:870-932-1820
Practice Address - Fax:870-972-6712
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1477749992OtherBCBS
ARP00735097OtherRAILROAD MEDICARE
AR5L807P139Medicare PIN