Provider Demographics
NPI:1629195664
Name:WINGATE, MARSHA K
Entity Type:Individual
Prefix:MRS
First Name:MARSHA
Middle Name:K
Last Name:WINGATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11725 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:KS
Mailing Address - Zip Code:66776-4050
Mailing Address - Country:US
Mailing Address - Phone:620-238-0239
Mailing Address - Fax:620-763-2296
Practice Address - Street 1:1902 S US HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:KS
Practice Address - Zip Code:67357-4948
Practice Address - Country:US
Practice Address - Phone:620-421-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS297133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS130638Medicare ID - Type UnspecifiedMEDICARE