Basic Information
| Provider Information | |||||||||
| NPI: | 1659399319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZACHER | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2963 W WHITE MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859296257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288659184 | ||||||||
| FaxNumber: | 9288657571 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BURRO ALY | ||||||||
| Address2: | |||||||||
| City: | MORENCI | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855409647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288659184 | ||||||||
| FaxNumber: | 9288657571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2560 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 634726 | 05 | AZ | MEDICAID |