Healthcare Provider Details

I. General information

NPI: 1205316056
Provider Name (Legal Business Name): ZACHARY TILTON STEVENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 02/22/2020
Certification Date: 02/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8720 14TH AVE S
SEATTLE WA
98108-4807
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 206-762-3730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: