Provider Demographics
NPI:1114934510
Name:WIRTH, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:WIRTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROAD STREET PLZ
Mailing Address - Street 2:PO BOX 357
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4390
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-745-1378
Practice Address - Street 1:3767 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1837
Practice Address - Country:US
Practice Address - Phone:518-623-2844
Practice Address - Fax:518-623-3416
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000572367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00630039Medicaid