Provider Demographics
NPI:1578500260
Name:WINGATE, PRESTON D (PA-C)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:D
Last Name:WINGATE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5018 CAHABA RIVER RD
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2317
Mailing Address - Country:US
Mailing Address - Phone:053-975-2002
Mailing Address - Fax:
Practice Address - Street 1:5018 CAHABA RIVER RD
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-2317
Practice Address - Country:US
Practice Address - Phone:053-975-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA174363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
933837Medicare UPIN
AL051556360WINMedicare UPIN