Healthcare Provider Details

I. General information

NPI: 1811574262
Provider Name (Legal Business Name): BRIAN WIRKUS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 LILLY RD NE
OLYMPIA WA
98506-5028
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-486-6772
  • Fax: 360-455-7405
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61148937
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: