1578966008 NPI number — KYRENE M ZACK PA-C

Table of content: KYRENE M ZACK PA-C (NPI 1578966008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578966008 NPI number — KYRENE M ZACK PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZACK
Provider First Name:
KYRENE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAYNES
Provider Other First Name:
KYRENE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578966008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
785 5TH AVE STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMBERSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17201-4232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-263-9555
Provider Business Mailing Address Fax Number:
717-709-6529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 ST PAUL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
CHAMBERSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17201-4221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-217-6870
Provider Business Practice Location Address Fax Number:
717-217-6945
Provider Enumeration Date:
09/29/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  MA057195 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: MA057195 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103157918 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".