Provider Demographics
NPI:1245600709
Name:WIERBOWSKI, AMY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:WIERBOWSKI
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 1:610 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9618
Mailing Address - Country:US
Mailing Address - Phone:570-357-9679
Mailing Address - Fax:
Practice Address - Street 1:1177 HIGHWAY 315 BLVD
Practice Address - Street 2:DOLPHIN PLAZA
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6928
Practice Address - Country:US
Practice Address - Phone:570-270-5713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057868363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50137303OtherCAPITAL BLUE CROSS
PA456984Medicare PIN