Provider Demographics
NPI:1427793165
Name:ZACCAGNINI, GARY SHANE (PTA)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:SHANE
Last Name:ZACCAGNINI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 MEMORIAL BLVD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:SC
Mailing Address - Zip Code:29477-2286
Mailing Address - Country:US
Mailing Address - Phone:843-638-5122
Mailing Address - Fax:843-638-5126
Practice Address - Street 1:5502 MEMORIAL BLVD UNIT 2
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:SC
Practice Address - Zip Code:29477-2286
Practice Address - Country:US
Practice Address - Phone:843-638-5122
Practice Address - Fax:843-638-5126
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2139225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant