Provider Demographics
NPI:1457855868
Name:MAUST, ZACK
Entity Type:Individual
Prefix:
First Name:ZACK
Middle Name:
Last Name:MAUST
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 1:70 WEEPING WILLOW DR APT B
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-3990
Mailing Address - Country:US
Mailing Address - Phone:154-055-6335
Mailing Address - Fax:
Practice Address - Street 1:70 WEEPING WILLOW DR APT B
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-3990
Practice Address - Country:US
Practice Address - Phone:540-556-3353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program