Healthcare Provider Details

I. General information

NPI: 1528462413
Provider Name (Legal Business Name): ZACHARY A STUTZMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27650 FERRY RD STE 100
WARRENVILLE IL
60555-3846
US

IV. Provider business mailing address

27650 FERRY RD STE 100
WARRENVILLE IL
60555-3846
US

V. Phone/Fax

Practice location:
  • Phone: 630-225-2663
  • Fax: 630-225-2399
Mailing address:
  • Phone: 630-225-2663
  • Fax: 630-225-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12524
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007592
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: