Provider Demographics
NPI:1720553506
Name:WIRTH, KAREN LISA
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LISA
Last Name:WIRTH
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 1:3581 OLD WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3270
Mailing Address - Country:US
Mailing Address - Phone:301-638-4400
Mailing Address - Fax:301-638-2200
Practice Address - Street 1:3581 OLD WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3270
Practice Address - Country:US
Practice Address - Phone:301-638-4400
Practice Address - Fax:301-638-2200
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily