Provider Demographics
NPI:1588625701
Name:ROBERTSON, ZACHARY (PA)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1829
Mailing Address - Street 2:D
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-1829
Mailing Address - Country:US
Mailing Address - Phone:918-379-6260
Mailing Address - Fax:918-293-3149
Practice Address - Street 1:1875 N HIGHWAY 66
Practice Address - Street 2:D
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-1829
Practice Address - Country:US
Practice Address - Phone:918-379-6260
Practice Address - Fax:918-293-3149
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1316363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ11521Medicare UPIN