Basic Information
| Provider Information | |||||||||
| NPI: | 1972613727 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINGO | ||||||||
| FirstName: | SHANA | ||||||||
| MiddleName: | NICOLLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 117287 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394328331 | ||||||||
| FaxNumber: | 8134992580 | ||||||||
| Practice Location | |||||||||
| Address1: | 2925 W ROSE GARDEN LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850273135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232657215 | ||||||||
| FaxNumber: | 8334651462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | M3796 | TX | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207VX0201X | 4443 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207VX0201X | 42887 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 519946 | 05 | AZ | MEDICAID |