Basic Information
| Provider Information | |||||||||
| NPI: | 1659840189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERVIN | ||||||||
| FirstName: | ZACHARY | ||||||||
| MiddleName: | HUNTER | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 WOOD CT | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376632769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237827171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 875 LARRY NEIL WAY | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232829570 | ||||||||
| FaxNumber: | 4232829572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2018 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11361 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11361 | 01 | TN | STATE LICENSE | OTHER |