Provider Demographics
NPI:1215364120
Name:JOHANNESEN, ZACHARY K
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:K
Last Name:JOHANNESEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:PO BOX 11223
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:800-516-5315
Mailing Address - Fax:517-787-7365
Practice Address - Street 1:5353 REYNOLDS REYNOLDS STREET
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6015
Practice Address - Country:US
Practice Address - Phone:912-819-6172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant