Healthcare Provider Details

I. General information

NPI: 1245850767
Provider Name (Legal Business Name): ZACHARY M BARNETT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 217-547-9100
  • Fax: 217-547-9236
Mailing address:
  • Phone: 217-547-9100
  • Fax: 217-547-9236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician 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: