MEDICARE: STEPHANIE LYNNE WIERZBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	019874	NY

General Provider Information

NPI Number	:	1902254667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LYNNE WIERZBA

Provider Business Mailing Address
First Line	:	2685 E HENRIETTA RD
Second Line	:
City	:	HENRIETTA
State	:	NY
Zip	:	14467-9370
Country	:	US
Telephone Number	:	585-444-0058
Fax Number	:

Provider Business Practice Location Address
First Line	:	2685 E HENRIETTA RD
Second Line	:
City	:	HENRIETTA
State	:	NY
Zip	:	14467-9370
Country	:	US
Telephone Number	:	585-444-0058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2016
Last Update Date	:	07/24/2016

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