Healthcare Provider Details

I. General information

NPI: 1851698674
Provider Name (Legal Business Name): ZACHARY ANDREW WULBECKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ZACK ANDREW WULBECKER PA-C

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 UNIVERSITY BLVD
NORTH CHARLESTON SC
29406-9121
US

IV. Provider business mailing address

PO BOX 118087
NORTH CHARLESTON SC
29423-8087
US

V. Phone/Fax

Practice location:
  • Phone: 438-637-4628
  • Fax:
Mailing address:
  • Phone: 843-863-7462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003686
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1580
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3497
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: