Provider Demographics
NPI:1689605081
Name:WINGROVE, BRIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WINGROVE
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 1:859 MOUNT VERNON HWY NE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4255
Mailing Address - Country:US
Mailing Address - Phone:404-785-0588
Mailing Address - Fax:404-785-0596
Practice Address - Street 1:859 MOUNT VERNON HWY NE STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4255
Practice Address - Country:US
Practice Address - Phone:404-785-0588
Practice Address - Fax:404-785-0596
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3990363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical