Provider Demographics
NPI:1295102739
Name:WINEGARDNER, JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WINEGARDNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 LAMB CIR STE 380
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-6345
Mailing Address - Country:US
Mailing Address - Phone:540-510-6200
Mailing Address - Fax:
Practice Address - Street 1:2900 LAMB CIR STE 380
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6345
Practice Address - Country:US
Practice Address - Phone:540-510-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP091363A00000X
VA0110006685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant