Provider Demographics
NPI:1528079951
Name:WYNEGAR, ELIZABETH W (PA)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:W
Last Name:WYNEGAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:R
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:300 MEDICAL PKWY
Mailing Address - Street 2:STE 120
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4985
Mailing Address - Country:US
Mailing Address - Phone:757-252-5660
Mailing Address - Fax:757-548-9443
Practice Address - Street 1:844 KEMPSVILLE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3927
Practice Address - Country:US
Practice Address - Phone:757-261-0700
Practice Address - Fax:757-962-1254
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001872207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010201616Medicaid
VA184972OtherANTHEM MEDIGAP
VAQ53403Medicare UPIN
VA010201616Medicaid