Provider Demographics
NPI:1013167956
Name:ZIKE, GREGORY D SR (PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:ZIKE
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8966 GOULD RD.
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347
Mailing Address - Country:US
Mailing Address - Phone:605-610-5648
Mailing Address - Fax:
Practice Address - Street 1:8966 GOULD RD
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-3326
Practice Address - Country:US
Practice Address - Phone:605-610-5648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0134363A00000X
IA1588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR92473Medicare UPIN