Provider Demographics
NPI:1952407678
Name:VAN WIRT, PAIGE ELIZABETH
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:ELIZABETH
Last Name:VAN WIRT
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 1:1 E BROAD ST STE 130
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-5934
Mailing Address - Country:US
Mailing Address - Phone:844-626-0480
Mailing Address - Fax:484-896-9002
Practice Address - Street 1:3477 CORPORATE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:CENTER VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18034-8237
Practice Address - Country:US
Practice Address - Phone:484-626-0480
Practice Address - Fax:484-896-9002
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC035842207R00000X
PAMD442199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037903400Medicaid
DC019354M65Medicare ID - Type Unspecified
DC037903400Medicaid
DC135367YT2Medicare PIN