Provider Demographics
NPI:1972269629
Name:LAGRUE, ZACHARY TAYLOR
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:TAYLOR
Last Name:LAGRUE
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 1:16 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18643-2832
Mailing Address - Country:US
Mailing Address - Phone:570-301-8108
Mailing Address - Fax:
Practice Address - Street 1:1099 S TOWNSHIP BLVD
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3247
Practice Address - Country:US
Practice Address - Phone:570-602-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant