Provider Demographics
NPI:1760934293
Name:GARRETT, ZACKARY CODY (PA-C)
Entity Type:Individual
Prefix:
First Name:ZACKARY
Middle Name:CODY
Last Name:GARRETT
Suffix:
Gender:M
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 1:3463 MAGIC DR
Mailing Address - Street 2:STE T21
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3621
Mailing Address - Country:US
Mailing Address - Phone:210-614-8101
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR FL 3
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA11388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX374406201Medicaid
TX374406202OtherCSHCN