Provider Demographics
NPI:1407135205
Name:IVY, ZACCARIAH DESMOND (PA)
Entity Type:Individual
Prefix:
First Name:ZACCARIAH
Middle Name:DESMOND
Last Name:IVY
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:720-979-0840
Mailing Address - Fax:303-861-4741
Practice Address - Street 1:14000 E ARAPAHOE RD
Practice Address - Street 2:#300
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-4043
Practice Address - Country:US
Practice Address - Phone:720-979-0840
Practice Address - Fax:303-861-4741
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2022-02-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO3256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11630582Medicaid
COCOAAA1287Medicare PIN