Provider Demographics
NPI:1518610724
Name:WILBERT, CHARLES ZACHARY (APRN)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ZACHARY
Last Name:WILBERT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8442 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-1140
Mailing Address - Country:US
Mailing Address - Phone:502-638-4280
Mailing Address - Fax:502-638-4281
Practice Address - Street 1:8442 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-1140
Practice Address - Country:US
Practice Address - Phone:502-638-4280
Practice Address - Fax:502-638-4281
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1129505163W00000X, 363L00000X
KY3017489363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3017489OtherLICENSE NUMBER