Healthcare Provider Details

I. General information

NPI: 1801639596
Provider Name (Legal Business Name): ZACHARY JOESPH WITGES AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR STE 230
ALTON IL
62002-6704
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-8512
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-7874
  • Fax: 314-996-7658
Mailing address:
  • Phone: 618-234-2390
  • Fax: 314-996-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.029825
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209029825
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2024043178
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: