Healthcare Provider Details

I. General information

NPI: 1457709602
Provider Name (Legal Business Name): SHAD WINGET
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2016
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NY
11747-2354
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-4101
  • Fax:
Mailing address:
  • Phone: 516-945-3116
  • Fax: 516-945-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number167658
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: