=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508355058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY ANTON NEVOLO DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2018
-----------------------------------------------------
Last Update Date | 05/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 BRIGHTWATER DR
-----------------------------------------------------
City | LILLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27546-5156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-892-1000
-----------------------------------------------------
Fax | 910-984-3708
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 40908
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28309-0908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-615-6949
-----------------------------------------------------
Fax | 910-615-9761
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS021033
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2022-01066
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------