Healthcare Provider Details

I. General information

NPI: 1043964125
Provider Name (Legal Business Name): SHIRA WURZBURGER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 TUDOR CT
LAKEWOOD NJ
08701-1472
US

IV. Provider business mailing address

103 TUDOR CT
LAKEWOOD NJ
08701-1472
US

V. Phone/Fax

Practice location:
  • Phone: 845-641-3463
  • Fax:
Mailing address:
  • Phone: 845-641-3463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01264900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: