Provider Demographics
NPI:1538997218
Name:PETTERSON, ZACHARY MARK (RN)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:MARK
Last Name:PETTERSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7922 DAY CREEK BLVD APT 1308
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8587
Mailing Address - Country:US
Mailing Address - Phone:925-314-6672
Mailing Address - Fax:
Practice Address - Street 1:100 S LOS ROBLES AVE # 501
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2453
Practice Address - Country:US
Practice Address - Phone:626-564-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95168572163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse