Provider Demographics
NPI:1811382617
Name:ROBERTSON, ZACHARY (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 TAMARACK DR APT D
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-9568
Mailing Address - Country:US
Mailing Address - Phone:906-236-1042
Mailing Address - Fax:
Practice Address - Street 1:4450 CAMP SWIFT RD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA1152042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program