Healthcare Provider Details

I. General information

NPI: 1619605250
Provider Name (Legal Business Name): ANDREW WIRTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 W CONE BLVD STE 110
GREENSBORO NC
27408-4045
US

IV. Provider business mailing address

24581 ENCHANTED DR
NOVI MI
48374-2947
US

V. Phone/Fax

Practice location:
  • Phone: 336-890-8902
  • Fax:
Mailing address:
  • Phone: 734-578-4074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: