Provider Demographics
NPI:1285185397
Name:PERIHAROS, ZACHARY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:
Last Name:PERIHAROS
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 1:1640 10TH AVE UNIT 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-740-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant