1245600709 NPI number — AMY MARIE WIERBOWSKI PA-C

Table of content: AMY MARIE WIERBOWSKI PA-C (NPI 1245600709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245600709 NPI number — AMY MARIE WIERBOWSKI PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIERBOWSKI
Provider First Name:
AMY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245600709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAVERTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18708-9618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-357-9679
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1177 HIGHWAY 315 BLVD
Provider Second Line Business Practice Location Address:
DOLPHIN PLAZA
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702-6928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-270-5713
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  MA057868 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50137303 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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