Basic Information
Provider Information | |||||||||
NPI: | 1528079951 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WYNEGAR | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILSON | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 300 MEDICAL PKWY | ||||||||
Address2: | STE 120 | ||||||||
City: | CHESAPEAKE | ||||||||
State: | VA | ||||||||
PostalCode: | 233204985 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572525660 | ||||||||
FaxNumber: | 7575489443 | ||||||||
Practice Location | |||||||||
Address1: | 844 KEMPSVILLE RD | ||||||||
Address2: | SUITE 204 | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235023927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572610700 | ||||||||
FaxNumber: | 7579621254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 08/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 0110001872 | VA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 010201616 | 05 | VA |   | MEDICAID | 184972 | 01 | VA | ANTHEM MEDIGAP | OTHER |