Provider Demographics
NPI:1760595664
Name:WINGREN, MICHAEL DAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAN
Last Name:WINGREN
Suffix:
Gender:M
Credentials:MD
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 1267
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-3267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1812 S J ST STE 120
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4965
Practice Address - Country:US
Practice Address - Phone:253-428-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028466174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1760595664Medicaid
WA0302697OtherL&I AND CRIME VICTIMS
WA1089457Medicaid
WAE51981Medicare UPIN
WA1760595664Medicaid