Basic Information
| Provider Information | |||||||||
| NPI: | 1366448615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WURST | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4408 DELWOOD LN | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324087492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506367000 | ||||||||
| FaxNumber: | 8506367072 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505224485 | ||||||||
| FaxNumber: | 8509146281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 01/29/2015 | ||||||||
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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 | 2084P0800X | ME55057 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 18041 | 01 | FL | BCBS OF FL | OTHER | 376103700 | 05 | FL | MEDICAID | 376103701 | 05 | FL | MEDICAID | 376103702 | 05 | FL | MEDICAID |