Provider Demographics
NPI:1063003176
Name:WIRTH, MADELEINE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:MARIE
Last Name:WIRTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 MERGANSER RUN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1080
Mailing Address - Country:US
Mailing Address - Phone:740-975-0602
Mailing Address - Fax:
Practice Address - Street 1:751 FOREST AVE STE 301
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2875
Practice Address - Country:US
Practice Address - Phone:740-455-4923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006840RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant