Provider Demographics
NPI:1982681094
Name:WIRTZ, RANDY L (ARNP)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:L
Last Name:WIRTZ
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:IA
Mailing Address - Zip Code:50622-9612
Mailing Address - Country:US
Mailing Address - Phone:319-984-5645
Mailing Address - Fax:319-984-5364
Practice Address - Street 1:160 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:IA
Practice Address - Zip Code:50622-9612
Practice Address - Country:US
Practice Address - Phone:319-984-5645
Practice Address - Fax:319-984-5364
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA056327363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0419940Medicaid
IA2419440Medicaid
IA38469OtherWELLMARK BC/BS IOWA
IAP00195265OtherRAILROAD MEDICARE
IA3419440Medicaid
S59297Medicare UPIN
IA56044Medicare ID - Type Unspecified
IA3419440Medicaid