Healthcare Provider Details

I. General information

NPI: 1851833271
Provider Name (Legal Business Name): ZACHARY THOMAS HERTZEL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 LAKELAND HILLS BLVD
LAKELAND FL
33805-1965
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE DEPT.
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-603-6565
  • Fax: 863-904-1961
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11077377-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: