Provider Demographics
NPI:1629687124
Name:WIRTH, JUSTIN ROBERT (DNP, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ROBERT
Last Name:WIRTH
Suffix:
Gender:M
Credentials:DNP, APRN, PMHNP-BC
Other - Prefix:DR
Other - First Name:JUSTIN
Other - Middle Name:ROBERT
Other - Last Name:WIRTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DNP, APRN, PMHNP-BC
Mailing Address - Street 1:15953 47TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55302-3902
Mailing Address - Country:US
Mailing Address - Phone:320-290-3895
Mailing Address - Fax:
Practice Address - Street 1:4801 VETERANS DR # 111
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-252-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7559363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health