Provider Demographics
NPI:1750124715
Name:NUSSBAUM, ZACHARY GAGE (PA-C)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:GAGE
Last Name:NUSSBAUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1492 S MILL AVE STE 206214
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-5652
Mailing Address - Country:US
Mailing Address - Phone:480-427-6645
Mailing Address - Fax:
Practice Address - Street 1:1492 S MILL AVE STE 206
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5664
Practice Address - Country:US
Practice Address - Phone:480-508-0882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
AZ10525363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical