Provider Demographics
NPI:1316213499
Name:BUDREW, ZACHARY ROSS
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ROSS
Last Name:BUDREW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 E PARKS HWY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7040
Mailing Address - Country:US
Mailing Address - Phone:907-357-5627
Mailing Address - Fax:
Practice Address - Street 1:357 E PARKS HWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7040
Practice Address - Country:US
Practice Address - Phone:907-357-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK920157161Medicaid