Healthcare Provider Details

I. General information

NPI: 1013167956
Provider Name (Legal Business Name): GREGORY D ZIKE SR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8966 GOULD RD
EDEN PRAIRIE MN
55347-3326
US

IV. Provider business mailing address

8966 GOULD RD.
EDEN PRAIRIE MN
55347
US

V. Phone/Fax

Practice location:
  • Phone: 605-610-5648
  • Fax:
Mailing address:
  • Phone: 605-610-5648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0134
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1588
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: