Healthcare Provider Details

I. General information

NPI: 1689589830
Provider Name (Legal Business Name): ZACHARY MARTIN RN, EMT-B
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

113 E GRACE ST
REPUBLIC MO
65738-2662
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-2115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2024026165
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: