Healthcare Provider Details

I. General information

NPI: 1720686090
Provider Name (Legal Business Name): ZACHARY R BOISSELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 05/30/2021
Certification Date: 05/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 S PRICE RD
CHANDLER AZ
85248-3544
US

IV. Provider business mailing address

1695 W DESERT WILLOW DR
COTTONWOOD AZ
86326-8300
US

V. Phone/Fax

Practice location:
  • Phone: 888-488-7640
  • Fax:
Mailing address:
  • Phone: 850-896-9575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number255182
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN157599
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: