Provider Demographics
NPI:1033766183
Name:WIRTH, JOSHUA ADAM
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ADAM
Last Name:WIRTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CALYPSO BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1431
Mailing Address - Country:US
Mailing Address - Phone:606-627-0159
Mailing Address - Fax:
Practice Address - Street 1:1740 NICHOLASVILLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1431
Practice Address - Country:US
Practice Address - Phone:859-260-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013369363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100626750Medicaid