Healthcare Provider Details

I. General information

NPI: 1619290822
Provider Name (Legal Business Name): NICOLE ELIZABETH ZACK NWOBODO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5605 W EUGIE AVE STE. 200
GLENDALE AZ
85304-1272
US

IV. Provider business mailing address

13965 N 75TH AVE
PEORIA AZ
85381-6097
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-2991
  • Fax: 602-978-1226
Mailing address:
  • Phone: 602-843-2991
  • Fax: 602-978-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5740
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10711
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: