Basic Information
| Provider Information | |||||||||
| NPI: | 1700487147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | ZACKERY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2017 W I 35 FRONTAGE RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730138555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057573710 | ||||||||
| FaxNumber: | 4057573711 | ||||||||
| Practice Location | |||||||||
| Address1: | 2017 W I 35 FRONTAGE RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730138555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057573710 | ||||||||
| FaxNumber: | 4057573711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2020 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 4394 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.