Basic Information
| Provider Information | |||||||||
| NPI: | 1982681094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRTZ | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506229612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3199845645 | ||||||||
| FaxNumber: | 3199845364 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506229612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3199845645 | ||||||||
| FaxNumber: | 3199845364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A056327 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0419940 | 05 | IA | MEDICAID | 2419440 | 05 | IA | MEDICAID | 38469 | 01 | IA | WELLMARK BC/BS IOWA | OTHER | P00195265 | 01 | IA | RAILROAD MEDICARE | OTHER | 3419440 | 05 | IA | MEDICAID |