Basic Information
| Provider Information | |||||||||
| NPI: | 1730170168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINGO | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706427572 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706427572 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E3749 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5M695 | 01 | AR | AR BCBS | OTHER |