Provider Demographics
NPI:1558946491
Name:WIRTH, COLLEEN MARY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:WIRTH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:
Practice Address - Street 1:425 ESSJAY RD STE 180
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5782
Practice Address - Country:US
Practice Address - Phone:716-630-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant