Provider Demographics
NPI:1184221160
Name:ORR, ZACHARY WADE (AGNP-C)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:WADE
Last Name:ORR
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2504
Mailing Address - Country:US
Mailing Address - Phone:217-257-8677
Mailing Address - Fax:
Practice Address - Street 1:1622 S 18TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2504
Practice Address - Country:US
Practice Address - Phone:217-257-8677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020030165363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner