Provider Demographics
NPI:1205988789
Name:WINGATE, SPENCER ANDREW (PT)
Entity type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:ANDREW
Last Name:WINGATE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-954-7408
Practice Address - Street 1:921 MOORES FERRY RD
Practice Address - Street 2:SUITE D
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-9703
Practice Address - Country:US
Practice Address - Phone:678-840-8881
Practice Address - Fax:678-840-8885
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003181174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDMQMedicare ID - Type Unspecified
GAQ67407Medicare UPIN