Provider Demographics
NPI:1013900877
Name:WIRTH, CAROL M (CRNA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:WIRTH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:M
Other - Last Name:DERGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-6101
Mailing Address - Country:US
Mailing Address - Phone:239-281-6722
Mailing Address - Fax:239-433-9569
Practice Address - Street 1:115 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-6101
Practice Address - Country:US
Practice Address - Phone:239-281-6722
Practice Address - Fax:239-433-9569
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3133532367500000X
IL209004737367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304460200Medicaid
G2100OtherBCBS
FL304460200Medicaid