Healthcare Provider Details

I. General information

NPI: 1760694434
Provider Name (Legal Business Name): STANLEY WIRSIG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 PURCHASE ST GREATER NEW BEDFORD COMMUNITY HEALTH CENTER
NEW BEDFORD MA
02740-6232
US

IV. Provider business mailing address

874 PURCHASE ST
NEW BEDFORD MA
02740-6232
US

V. Phone/Fax

Practice location:
  • Phone: 508-992-6553
  • Fax: 508-990-7558
Mailing address:
  • Phone: 508-992-6553
  • Fax: 508-990-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number903
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: