Provider Demographics
NPI:1376107979
Name:WILSON, JOHN ZAAKERY (PSS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ZAAKERY
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7017
Mailing Address - Country:US
Mailing Address - Phone:907-357-8780
Mailing Address - Fax:
Practice Address - Street 1:3350 E BEECH WAY # A
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7417
Practice Address - Country:US
Practice Address - Phone:760-808-0251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK7005862OtherDRIVERS LICENSE