Provider Demographics
NPI:1275925422
Name:CLOUSE, ZACK (PA-C)
Entity Type:Individual
Prefix:
First Name:ZACK
Middle Name:
Last Name:CLOUSE
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 951231
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:793 W STATE ST
Practice Address - Street 2:3 NORTH 09
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1551
Practice Address - Country:US
Practice Address - Phone:614-234-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant