Healthcare Provider Details

I. General information

NPI: 1740911270
Provider Name (Legal Business Name): ALEXANDER ZACHARY PERSYN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5087 N ROYAL DR STE B
TRAVERSE CITY MI
49684-6987
US

IV. Provider business mailing address

5087 N ROYAL DR STE B
TRAVERSE CITY MI
49684-6987
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0440
  • Fax: 231-935-0445
Mailing address:
  • Phone: 231-935-0440
  • Fax: 231-935-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011259
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: