Provider Demographics
NPI:1174299051
Name:VANDALL, ZACHARY TAYLOR (CSA/LSA)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:TAYLOR
Last Name:VANDALL
Suffix:
Gender:M
Credentials:CSA/LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8104 FOXCATCHER CT
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-6544
Mailing Address - Country:US
Mailing Address - Phone:577-968-8387
Mailing Address - Fax:
Practice Address - Street 1:13710 ST FRANCIS BLVD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3267
Practice Address - Country:US
Practice Address - Phone:804-594-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000367246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant