Individual
MRS. KISUK BAE WIRTZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
114 FRAZEE ST E, 47854 SWISS LANE, DETROIT LAKES, MN 56501-3502
(218) 573-3898
Mailing address
PO BOX 884, 47854 SWISS LANE, PONSFORD, MN 56575
(218) 573-3898
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
L48823-7
MN
Other
Enumeration date
06/21/2010
Last updated
06/21/2010
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