Provider Demographics
NPI:1740891779
Name:WINGFIELD, JOHN CALLAWAY (PTA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CALLAWAY
Last Name:WINGFIELD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 S LUMPKIN ST APT 27
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6610
Mailing Address - Country:US
Mailing Address - Phone:571-216-7301
Mailing Address - Fax:
Practice Address - Street 1:788 PRINCE AVE STE C
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5912
Practice Address - Country:US
Practice Address - Phone:706-543-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003308225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant