Provider Demographics
NPI:1598841728
Name:WINGATE, FRED B (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:B
Last Name:WINGATE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
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 2177
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766
Mailing Address - Country:US
Mailing Address - Phone:903-586-2415
Mailing Address - Fax:903-586-2415
Practice Address - Street 1:510 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-4910
Practice Address - Country:US
Practice Address - Phone:903-586-2415
Practice Address - Fax:903-586-2415
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX650320Medicare ID - Type Unspecified