Healthcare Provider Details

I. General information

NPI: 1831188424
Provider Name (Legal Business Name): GLENN WURTZEL MS, NP-P, APRN-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 RIVERSIDE DR SUITE 1-O
NEW YORK NY
10024-2605
US

IV. Provider business mailing address

140 RIVERSIDE DR SUITE 1-O
NEW YORK NY
10024-2605
US

V. Phone/Fax

Practice location:
  • Phone: 212-988-4704
  • Fax: 212-988-4706
Mailing address:
  • Phone: 212-988-4704
  • Fax: 212-988-4706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number517707
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number400680
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: