Provider Demographics
NPI:1386859890
Name:KIRSCHBAUM, WYNNE M (PA)
Entity Type:Individual
Prefix:
First Name:WYNNE
Middle Name:M
Last Name:KIRSCHBAUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 COLLEGE PKWY
Mailing Address - Street 2:SUITE302
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-3052
Mailing Address - Country:US
Mailing Address - Phone:802-655-4900
Mailing Address - Fax:802-655-5017
Practice Address - Street 1:792 COLLEGE PKWY
Practice Address - Street 2:SUITE302
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3052
Practice Address - Country:US
Practice Address - Phone:802-655-4900
Practice Address - Fax:802-655-5017
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030813363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000350Medicaid
VT0000959Medicare PIN