Provider Demographics
NPI:1891291316
Name:WILKES, ZACKERY ROSS (NP-C)
Entity Type:Individual
Prefix:
First Name:ZACKERY
Middle Name:ROSS
Last Name:WILKES
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 W 7460 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3731
Mailing Address - Country:US
Mailing Address - Phone:801-903-3859
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST # 510
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6767
Practice Address - Country:US
Practice Address - Phone:801-507-3513
Practice Address - Fax:801-507-3584
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6860371-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily