Basic Information
| Provider Information | |||||||||
| NPI: | 1700246238 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLEASON | ||||||||
| FirstName: | ZACHARY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 MOUNTAIN LEDGE | ||||||||
| Address2: | |||||||||
| City: | GANSEVOORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128312539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185840335 | ||||||||
| FaxNumber: | 5185837665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2016 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 657120 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 340358 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 04401745 | 05 | NY | MEDICAID |