Healthcare Provider Details

I. General information

NPI: 1528079951
Provider Name (Legal Business Name): ELIZABETH W WYNEGAR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH R WILSON PA

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 KEMPSVILLE RD SUITE 204
NORFOLK VA
23502-3927
US

IV. Provider business mailing address

300 MEDICAL PKWY STE 120
CHESAPEAKE VA
23320-4985
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-0700
  • Fax: 757-962-1254
Mailing address:
  • Phone: 757-252-5660
  • Fax: 757-548-9443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0110001872
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: