Provider Demographics
NPI:1740414143
Name:VAN WYNGARDEN, MARY PATRICIA (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:PATRICIA
Last Name:VAN WYNGARDEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 W MAIN ST
Mailing Address - Street 2:STE D
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366
Mailing Address - Country:US
Mailing Address - Phone:209-599-2699
Mailing Address - Fax:209-599-5465
Practice Address - Street 1:1444 W MAIN ST
Practice Address - Street 2:STE D
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-3030
Practice Address - Country:US
Practice Address - Phone:209-599-2699
Practice Address - Fax:209-599-5465
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27179111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0271790Medicare PIN