MEDICARE: MR. THOMAS JAMES ZASTROW PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085.007982	IL

General Provider Information

NPI Number	:	1679193460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS JAMES ZASTROW PA-C

Provider Business Mailing Address
First Line	:	1663 BELVIDERE RD
Second Line	:
City	:	BELVIDERE
State	:	IL
Zip	:	61008-9306
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1663 BELVIDERE RD
Second Line	:
City	:	BELVIDERE
State	:	IL
Zip	:	61008-9306
Country	:	US
Telephone Number	:	815-544-0040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2020
Last Update Date	:	12/03/2020

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