Healthcare Provider Details

I. General information

NPI: 1669897849
Provider Name (Legal Business Name): ZACHARY WAJVODA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

IV. Provider business mailing address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

V. Phone/Fax

Practice location:
  • Phone: 219-798-0474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54127
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: