Provider Demographics
NPI:1861624868
Name:SWANSON, ZACHARY (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5730
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5700
Mailing Address - Country:US
Mailing Address - Phone:888-402-7256
Mailing Address - Fax:
Practice Address - Street 1:215 E QUINCY ST STE 604
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-2019
Practice Address - Country:US
Practice Address - Phone:210-798-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12393363AS0400X
TNPA2329363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1861624868Medicaid
TN1531975Medicaid