MEDICARE: KAITLYN RAE WIRTZ PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		ND

General Provider Information

NPI Number	:	1649839846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN RAE WIRTZ PA-C

Provider Business Mailing Address
First Line	:	PO BOX 280
Second Line	:
City	:	TURTLE LAKE
State	:	ND
Zip	:	58575-0280
Country	:	US
Telephone Number	:	701-448-2331
Fax Number	:	701-448-2441

Provider Business Practice Location Address
First Line	:	1177 BORDER LN
Second Line	:
City	:	WASHBURN
State	:	ND
Zip	:	58577-4102
Country	:	US
Telephone Number	:	701-462-3396
Fax Number	:	701-463-3422

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	06/11/2019

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