Provider Demographics
NPI:1790802593
Name:WINGFIELD, GARY ALAN
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:ALAN
Last Name:WINGFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SPEEDWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-5566
Mailing Address - Country:US
Mailing Address - Phone:406-549-8127
Mailing Address - Fax:406-542-5202
Practice Address - Street 1:1300 SPEEDWAY AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-5566
Practice Address - Country:US
Practice Address - Phone:406-549-8127
Practice Address - Fax:406-542-5202
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10995310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0601477Medicaid