Provider Demographics
NPI:1871811646
Name:WING SURGICAL PA
Entity type:Organization
Organization Name:WING SURGICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MELDRUM
Authorized Official - Last Name:WING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-322-7761
Mailing Address - Street 1:309 N MANGOUSTINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1098
Mailing Address - Country:US
Mailing Address - Phone:407-322-7761
Mailing Address - Fax:407-322-7763
Practice Address - Street 1:309 N MANGOUSTINE AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1098
Practice Address - Country:US
Practice Address - Phone:407-322-7761
Practice Address - Fax:407-322-7763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6027612086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty