Provider Demographics
NPI:1851698674
Name:WULBECKER, ZACHARY ANDREW
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ANDREW
Last Name:WULBECKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ZACK
Other - Middle Name:ANDREW
Other - Last Name:WULBECKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 118087
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29423-8087
Mailing Address - Country:US
Mailing Address - Phone:843-863-7462
Mailing Address - Fax:
Practice Address - Street 1:9200 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9121
Practice Address - Country:US
Practice Address - Phone:438-637-4628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003686363A00000X
NE1580363AM0700X
SC3497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25779231Medicaid
COP01212979OtherRAILROAD MEDICARE PIN
CO284916YLA0Medicare PIN