Healthcare Provider Details

I. General information

NPI: 1164336152
Provider Name (Legal Business Name): DEREK KURT WOLFGANG ZELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

PO BOX 51498
PHOENIX AZ
85076-1498
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12063
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: