Provider Demographics
NPI:1700507670
Name:ELIASON, ZACKARY W (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ZACKARY
Middle Name:W
Last Name:ELIASON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55388-9275
Mailing Address - Country:US
Mailing Address - Phone:952-457-9105
Mailing Address - Fax:
Practice Address - Street 1:976 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3014
Practice Address - Country:US
Practice Address - Phone:651-292-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist