Provider Demographics
NPI:1588234033
Name:WATSON, ZACKARY CHARLES
Entity Type:Individual
Prefix:
First Name:ZACKARY
Middle Name:CHARLES
Last Name:WATSON
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 1:415 W GOLF RD STE 26
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3923
Mailing Address - Country:US
Mailing Address - Phone:224-777-8034
Mailing Address - Fax:224-236-4900
Practice Address - Street 1:1321 CEDAR LN
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2227
Practice Address - Country:US
Practice Address - Phone:931-222-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.2066363A00000X
TN5284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant