Healthcare Provider Details

I. General information

NPI: 1740111079
Provider Name (Legal Business Name): NICHOLAS ZAJAC FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4038 VIOLET ST
LA MESA CA
91941-7544
US

IV. Provider business mailing address

4038 VIOLET ST
LA MESA CA
91941-7544
US

V. Phone/Fax

Practice location:
  • Phone: 419-654-4452
  • Fax:
Mailing address:
  • Phone: 419-654-4452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704450107
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: