Provider Demographics
NPI:1912638271
Name:WILSON, ZACHARY SCOTT (AGAC-NP)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:SCOTT
Last Name:WILSON
Suffix:
Gender:M
Credentials:AGAC-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 E BERT KOUN LOOP STE 112
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-6810
Mailing Address - Country:US
Mailing Address - Phone:318-223-5777
Mailing Address - Fax:
Practice Address - Street 1:1453 E BERT KOUN LOOP STE 112
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-6810
Practice Address - Country:US
Practice Address - Phone:318-223-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-18
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA226165363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty