Basic Information
| Provider Information | |||||||||
| NPI: | 1043982242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINGO | ||||||||
| FirstName: | HALEY | ||||||||
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| Credential: | CAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4623 RIBAULT PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322332439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788631870 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 PRUDENTIAL DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042028000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | AA687 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.