Provider Demographics
NPI:1861680704
Name:SOWA, ZACHARY LEE (PA)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:LEE
Last Name:SOWA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1900 E LAKE SHORE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3846
Mailing Address - Country:US
Mailing Address - Phone:217-464-1030
Mailing Address - Fax:217-464-1039
Practice Address - Street 1:1900 E LAKE SHORE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3846
Practice Address - Country:US
Practice Address - Phone:217-464-1030
Practice Address - Fax:217-464-1039
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5815191OtherBC/BS
ILIL2868074Medicare PIN
ILK50040Medicare UPIN
ILK50040Medicare PIN