Provider Demographics
NPI:1801295134
Name:LINES, ZACHARY A
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:A
Last Name:LINES
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 1:4030 RED HAWK RUN
Mailing Address - Street 2:
Mailing Address - City:BLACK EARTH
Mailing Address - State:WI
Mailing Address - Zip Code:53515-9482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 S FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1782
Practice Address - Country:US
Practice Address - Phone:773-257-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1117940363A00000X
IL085005161363A00000X
WI4350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085005161OtherILLINOIS STATE LICENSE
IA1117940OtherNCCPA CERTIFICATION NUMBER