Provider Demographics
NPI:1902254667
Name:WIERZBA, STEPHANIE LYNNE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNNE
Last Name:WIERZBA
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 1:2685 E HENRIETTA RD
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14467-9370
Mailing Address - Country:US
Mailing Address - Phone:585-444-0058
Mailing Address - Fax:
Practice Address - Street 1:2685 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14467-9370
Practice Address - Country:US
Practice Address - Phone:585-444-0058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant