Provider Demographics
NPI:1588625701
Name:ROBERTSON, ZACHARY (PA)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W BLUE STARR DR
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-4006
Mailing Address - Country:US
Mailing Address - Phone:918-343-6000
Mailing Address - Fax:918-274-8556
Practice Address - Street 1:401 W BLUE STARR DR
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-4006
Practice Address - Country:US
Practice Address - Phone:918-343-6000
Practice Address - Fax:918-274-8556
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1316363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ11521Medicare UPIN