Healthcare Provider Details

I. General information

NPI: 1215207956
Provider Name (Legal Business Name): PEDRO EFREN ZAMORA CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11645 MONUMENT DR UNIT 1138
LAKEWOOD RANCH FL
34211-1281
US

IV. Provider business mailing address

11645 MONUMENT DR UNIT 1138
LAKEWOOD RANCH FL
34211-1281
US

V. Phone/Fax

Practice location:
  • Phone: 360-914-6048
  • Fax:
Mailing address:
  • Phone: 360-914-6048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: