MEDICARE: MR. ZACHARY M KERSTEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	UNKNOWN	OTHER		TRICARE

General Provider Information

NPI Number	:	1972067635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ZACHARY M KERSTEN

Provider Business Mailing Address
First Line	:	634 E BEAR BLVD APT 309
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65806-3821
Country	:	US
Telephone Number	:	618-980-9310
Fax Number	:

Provider Business Practice Location Address
First Line	:	634 E BEAR BLVD APT 309
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65806-3821
Country	:	US
Telephone Number	:	618-980-9310
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2019
Last Update Date	:	01/28/2019

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