Basic Information
| Provider Information | |||||||||
| NPI: | 1841382827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZACKER | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 W OKLAHOMA AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496588 | ||||||||
| FaxNumber: | 7702371723 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 W OKLAHOMA AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496588 | ||||||||
| FaxNumber: | 7702371723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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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 | 363A00000X | 1915-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 001 | 01 | WI | BCBS | OTHER |