Provider Demographics
NPI:1497087316
Name:WIERZBA, MATTHEW J (LAC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:WIERZBA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-2501
Mailing Address - Country:US
Mailing Address - Phone:207-442-0885
Mailing Address - Fax:
Practice Address - Street 1:9 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-2501
Practice Address - Country:US
Practice Address - Phone:207-442-0885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC 213171100000X
CA12626171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist