MEDICARE: BRANDON DEAN WINGATE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247100000X	Radiologic Technologist	346808	TN
2	2471S1302X	Sonography Radiologic Technologist	112229	TN
3	2471V0105X	Vascular Sonography Radiologic Technologist	112229	TN

General Provider Information

NPI Number	:	1265796114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON DEAN WINGATE

Provider Business Mailing Address
First Line	:	323 SAVANNAH RDG
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37127-8331
Country	:	US
Telephone Number	:	615-306-9298
Fax Number	:

Provider Business Practice Location Address
First Line	:	323 SAVANNAH RDG
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37127-8331
Country	:	US
Telephone Number	:	615-306-9298
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2012
Last Update Date	:	07/10/2012

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