Provider Demographics
NPI:1679116040
Name:WINNEGAN, RAYMOND CHARLES
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:CHARLES
Last Name:WINNEGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10080 STALLINGS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-4418
Mailing Address - Country:US
Mailing Address - Phone:757-371-8008
Mailing Address - Fax:
Practice Address - Street 1:10080 STALLINGS CREEK DR
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430-4418
Practice Address - Country:US
Practice Address - Phone:757-371-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
VA104791343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Single Specialty
No171W00000XOther Service ProvidersContractorGroup - Single Specialty