Provider Demographics
NPI:1467971432
Name:ROLLINS, ZACHARIAH LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:ZACHARIAH
Middle Name:LEE
Last Name:ROLLINS
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 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:
Practice Address - Street 1:500 S 11TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4880
Practice Address - Country:US
Practice Address - Phone:208-232-7862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1518363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant