Provider Demographics
NPI:1306896881
Name:WILSON, ZACHARY PAUL (DC)
Entity type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 PROGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-3108
Mailing Address - Country:US
Mailing Address - Phone:319-232-5366
Mailing Address - Fax:319-232-5370
Practice Address - Street 1:751 PROGRESS AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-3108
Practice Address - Country:US
Practice Address - Phone:319-232-5366
Practice Address - Fax:319-232-5370
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06838111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0485664Medicaid
IA0485672Medicaid
IAV09101Medicare UPIN
IAI17461Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
IAI17460Medicare ID - Type UnspecifiedMEDICARE GROUP