Healthcare Provider Details

I. General information

NPI: 1922214378
Provider Name (Legal Business Name): ZACHARY DUKANE PRYOR IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 03/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 10TH STREET BEACH MASTER UNIT TWO
VIRGINIA BEACH VA
23459
US

IV. Provider business mailing address

123 SEWELL RD
JACKSONVILLE NC
28540-9607
US

V. Phone/Fax

Practice location:
  • Phone: 757-462-7205
  • Fax:
Mailing address:
  • Phone: 910-346-4076
  • Fax: 910-346-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: