Provider Demographics
NPI:1255398830
Name:WIRTZ, JASON JOHN (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:JOHN
Last Name:WIRTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1959 SLOAN PLACE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2074
Mailing Address - Country:US
Mailing Address - Phone:651-772-6235
Mailing Address - Fax:651-772-6261
Practice Address - Street 1:1959 SLOAN PLACE
Practice Address - Street 2:SUITE 200
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-2074
Practice Address - Country:US
Practice Address - Phone:651-772-6235
Practice Address - Fax:651-772-6261
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-03-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN44626207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN324537300Medicaid
MN440000159Medicare UPIN
H47298Medicare UPIN