Provider Demographics
NPI:1164670105
Name:VANCE, ZACHARY R (PA-C)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:R
Last Name:VANCE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-1518
Practice Address - Street 1:57 SUTPHIN LANE
Practice Address - Street 2:
Practice Address - City:SCARBRO
Practice Address - State:WV
Practice Address - Zip Code:25917
Practice Address - Country:US
Practice Address - Phone:304-469-3345
Practice Address - Fax:304-469-2981
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013543Medicaid
WV3810013543Medicaid
WV2031193Medicare PIN
WVWV0670GMedicare PIN
WVPA36311Medicare PIN
WV2031191Medicare PIN