Healthcare Provider Details

I. General information

NPI: 1881099281
Provider Name (Legal Business Name): ZACHARY W SOUTHARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

IV. Provider business mailing address

PO BOX 8031
APPLETON WI
54912-8031
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-2000
  • Fax: 920-224-1706
Mailing address:
  • Phone: 866-313-0337
  • Fax: 920-224-1706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number163376
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: