Provider Demographics
NPI:1457672800
Name:WIRTZ, KISUK BAE
Entity Type:Individual
Prefix:MRS
First Name:KISUK
Middle Name:BAE
Last Name:WIRTZ
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:PO BOX 884
Mailing Address - Street 2:47854 SWISS LANE
Mailing Address - City:PONSFORD
Mailing Address - State:MN
Mailing Address - Zip Code:56575
Mailing Address - Country:US
Mailing Address - Phone:218-573-3898
Mailing Address - Fax:
Practice Address - Street 1:114 FRAZEE ST E
Practice Address - Street 2:47854 SWISS LANE
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3502
Practice Address - Country:US
Practice Address - Phone:218-573-3898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL48823-7164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse