Basic Information
| Provider Information | |||||||||
| NPI: | 1255398830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRTZ | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1959 SLOAN PLACE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551172074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517726235 | ||||||||
| FaxNumber: | 6517726261 | ||||||||
| Practice Location | |||||||||
| Address1: | 1959 SLOAN PLACE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551172074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517726235 | ||||||||
| FaxNumber: | 6517726261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 44626 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 44626 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 324537300 | 05 | MN | MEDICAID |