Healthcare Provider Details

I. General information

NPI: 1740156421
Provider Name (Legal Business Name): JUSTIN WINGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2025
Last Update Date: 10/11/2025
Certification Date: 10/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 X ST
SACRAMENTO CA
95817-2214
US

IV. Provider business mailing address

8555 WILLINGS WAY
FAIR OAKS CA
95628-6234
US

V. Phone/Fax

Practice location:
  • Phone: 916-703-6697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95108787
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberA7006495
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number95108787
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95108787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: