Provider Demographics
NPI:1720021918
Name:GEWIRZ, MARJORIE NIKKI (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:NIKKI
Last Name:GEWIRZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 S MAIN ST
Mailing Address - Street 2:SURGICAL ASSOCIATES
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-1381
Mailing Address - Country:US
Mailing Address - Phone:802-728-2372
Mailing Address - Fax:802-728-2613
Practice Address - Street 1:44 S MAIN ST
Practice Address - Street 2:SURGICAL ASSOCIATES
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1381
Practice Address - Country:US
Practice Address - Phone:802-728-2372
Practice Address - Fax:802-728-2613
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0581363AS0400X
VT055-0031029363AS0400X
VT055-0030993363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0013358OtherMEDICARE PTAN
VT9000284Medicaid
VT9000284Medicaid