Healthcare Provider Details

I. General information

NPI: 1932190543
Provider Name (Legal Business Name): NORMAN DALE ZELLERS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST # 81MDOS
BILOXI MS
39534-2508
US

IV. Provider business mailing address

301 FISHER ST # 81MDOS
BILOXI MS
39534-2508
US

V. Phone/Fax

Practice location:
  • Phone: 229-376-0500
  • Fax:
Mailing address:
  • Phone: 229-376-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00732
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: