Provider Demographics
NPI:1265488209
Name:WIRT, BENJAMIN LAFAYETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:LAFAYETTE
Last Name:WIRT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:L
Other - Last Name:WIRT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2871 ACTON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2560
Mailing Address - Country:US
Mailing Address - Phone:205-716-6900
Mailing Address - Fax:205-939-0293
Practice Address - Street 1:2871 ACTON RD STE 100
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243
Practice Address - Country:US
Practice Address - Phone:205-716-6900
Practice Address - Fax:205-939-0293
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-90363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000042296Medicaid
AL000042296Medicaid
AL510I970056Medicare PIN
ALP00653647Medicare PIN
AL000042296Medicare ID - Type Unspecified