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General NPI Number Information
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NPI Number | 1871811646
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Entity Type | Organization
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Legal Business Name | WING SURGICAL PA
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Dates
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Enumeration Date | 05/04/2010
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Last Update Date | 05/10/2010
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Provider Practice Location Address
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Address Line | 309 N MANGOUSTINE AVE
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City | SANFORD
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State | FL
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Zip | 32771-1098
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Country | US
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Telephone | 407-322-7761
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Fax | 407-322-7763
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Provider Business Mailing Address
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Address Line | 309 N MANGOUSTINE AVE
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City | SANFORD
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State | FL
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Zip | 32771-1098
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Country | US
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Telephone | 407-322-7761
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Fax | 407-322-7763
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. KENNETH MELDRUM WING
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Credential | M.D.
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Telephone | 407-322-7761
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | 602761
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License Number State | FL
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