=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912830738
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY JOHN BOULDEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2026
-----------------------------------------------------
Last Update Date | 06/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 GOPHER DR
-----------------------------------------------------
City | TOMAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54660-4513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-372-2181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1707 BRIDGER DR
-----------------------------------------------------
City | HOLMEN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54636-8847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 4347-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------