Provider Demographics
NPI:1649755372
Name:GRADOLPH, ZACHARY ALEXANDER
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ALEXANDER
Last Name:GRADOLPH
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 1:255 FAIRFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-3330
Mailing Address - Country:US
Mailing Address - Phone:404-405-1423
Mailing Address - Fax:
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:404-501-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN227950367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered