Provider Demographics
NPI:1720686090
Name:BOISSELLE, ZACHARY R
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:R
Last Name:BOISSELLE
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 1:1695 W DESERT WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-8300
Mailing Address - Country:US
Mailing Address - Phone:850-896-9575
Mailing Address - Fax:
Practice Address - Street 1:3115 S PRICE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-3544
Practice Address - Country:US
Practice Address - Phone:888-488-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN157599163W00000X
AZ255182363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse