Healthcare Provider Details

I. General information

NPI: 1114934510
Provider Name (Legal Business Name): VICTORIA WIRTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3767 MAIN ST
WARRENSBURG NY
12885-1837
US

IV. Provider business mailing address

1 BROAD STREET PLZ PO BOX 357
GLENS FALLS NY
12801-4390
US

V. Phone/Fax

Practice location:
  • Phone: 518-623-2844
  • Fax: 518-623-3416
Mailing address:
  • Phone: 518-761-0300
  • Fax: 518-745-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number000572
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: