Healthcare Provider Details

I. General information

NPI: 1790332245
Provider Name (Legal Business Name): JOHN CLAYTON ZIMBARDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 5TH ST
RAPID CITY SD
57701-6003
US

IV. Provider business mailing address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-5700
  • Fax:
Mailing address:
  • Phone: 805-630-0816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1308
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1308
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: