Healthcare Provider Details

I. General information

NPI: 1750999660
Provider Name (Legal Business Name): MICHAEL ZACKERY ZDUNICH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8004 MYRTLE TRACE DR
CONWAY SC
29526-8945
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD ATTN CREDENTIALING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-8041
  • Fax: 843-347-8042
Mailing address:
  • Phone: 843-234-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3654
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: