Provider Demographics
NPI:1811377799
Name:ELLIOTT, ZACHARY WADE (ATC)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:WADE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:201 PLAZA DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5105
Mailing Address - Country:US
Mailing Address - Phone:573-472-2663
Mailing Address - Fax:573-472-2669
Practice Address - Street 1:201 PLAZA DR
Practice Address - Street 2:SUITE A
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5105
Practice Address - Country:US
Practice Address - Phone:573-472-2663
Practice Address - Fax:573-472-2669
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140433032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer