Provider Demographics
NPI:1134471857
Name:WIRTZ, TIMOTHY M (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:WIRTZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 S CEDAR CREST BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6258
Mailing Address - Country:US
Mailing Address - Phone:610-402-8896
Mailing Address - Fax:610-402-9029
Practice Address - Street 1:1245 S CEDAR CREST BLVD STE 301
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6258
Practice Address - Country:US
Practice Address - Phone:610-402-8896
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN527078-L163W00000X
PA91019367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1613616OtherGATEWAY
PA1027793790001Medicaid
PA1134471857OtherGEISINGER
PA50111779OtherCAPITAL ADVANTAGE
PA1134471857OtherHIGHMARK
PA3888598000OtherIND. BLUE CROSS
PA12447546OtherCAQH
PA2745893OtherFIRST PRIORITY
PA9551934OtherAETNA
PA12447546OtherCAQH