Healthcare Provider Details

I. General information

NPI: 1750124715
Provider Name (Legal Business Name): ZACHARY GAGE NUSSBAUM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 S MILL AVE STE 206
TEMPE AZ
85281-5664
US

IV. Provider business mailing address

1492 S MILL AVE STE 206214
TEMPE AZ
85281-5652
US

V. Phone/Fax

Practice location:
  • Phone: 480-508-0882
  • Fax:
Mailing address:
  • Phone: 480-427-6645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10525
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10525
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: