Healthcare Provider Details

I. General information

NPI: 1891291316
Provider Name (Legal Business Name): ZACKERY ROSS WILKES NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST # 510
MURRAY UT
84107-6767
US

IV. Provider business mailing address

2800 W 7460 S
WEST JORDAN UT
84084-3731
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3513
  • Fax: 801-507-3584
Mailing address:
  • Phone: 801-903-3859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6860371-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: