Healthcare Provider Details

I. General information

NPI: 1255328787
Provider Name (Legal Business Name): ANDREW WINGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N SANTIAM HWY
LEBANON OR
97355-4363
US

IV. Provider business mailing address

15090 FALL RIVER DR
BEND OR
97707-2704
US

V. Phone/Fax

Practice location:
  • Phone: 541-258-2101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01055695A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD161507
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: