Healthcare Provider Details

I. General information

NPI: 1316636103
Provider Name (Legal Business Name): KARA MICHELLE WIRTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61
FESTUS MO
63028-4100
US

IV. Provider business mailing address

7 GEMSTONE DR
MILLSTADT IL
62260-2284
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2023023494
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: