Provider Demographics
NPI:1851975577
Name:FLACCAVENTO, ZACHARY WILLIAM
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:WILLIAM
Last Name:FLACCAVENTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 NEW BERN AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2989
Mailing Address - Country:US
Mailing Address - Phone:919-231-3966
Mailing Address - Fax:919-231-3912
Practice Address - Street 1:3031 NEW BERN AVE STE 306
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2989
Practice Address - Country:US
Practice Address - Phone:919-231-3966
Practice Address - Fax:919-231-3912
Is Sole Proprietor?:No
Enumeration Date:2021-05-09
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11539363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant