Provider Demographics
NPI:1972613727
Name:WINGO, SHANA NICOLLE (MD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:NICOLLE
Last Name:WINGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21812 N 37TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2925 W ROSE GARDEN LN STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3135
Practice Address - Country:US
Practice Address - Phone:623-265-7215
Practice Address - Fax:833-465-1462
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4443207VX0201X
TXM3796207VX0201X
AZ42887207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ519946Medicaid
AZZ139083Medicare PIN