Provider Demographics
NPI:1659399319
Name:ZACHER, BONNIE G (PA C)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:G
Last Name:ZACHER
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2963 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6257
Mailing Address - Country:US
Mailing Address - Phone:928-865-9184
Mailing Address - Fax:928-865-7571
Practice Address - Street 1:401 BURRO ALY
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:AZ
Practice Address - Zip Code:85540-9647
Practice Address - Country:US
Practice Address - Phone:928-865-9184
Practice Address - Fax:928-865-7571
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ634726Medicaid
AZ634726Medicaid