Provider Demographics
NPI:1649517731
Name:EBNER, ZACHARY D (CPED)
Entity type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:D
Last Name:EBNER
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 HARDING RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3154
Mailing Address - Country:US
Mailing Address - Phone:262-484-7677
Mailing Address - Fax:262-654-4305
Practice Address - Street 1:5027 GREEN BAY RD STE 124
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1771
Practice Address - Country:US
Practice Address - Phone:262-654-4300
Practice Address - Fax:262-654-4305
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICPED3822OtherABC CERTIFICATION