Basic Information
| Provider Information | |||||||||
| NPI: | 1477540722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKRONIS | ||||||||
| FirstName: | ZACHARIAS | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | PAAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3155 N POINT PKWY | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT, BUILDING F, SUITE 100 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Practice Location | |||||||||
| Address1: | 677 CHURCH ST NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707940477 | ||||||||
| FaxNumber: | 7707943108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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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 | 367H00000X | 3186 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100002656I | 05 | GA | MEDICAID | 100002656A | 05 | GA | MEDICAID | 100002656J | 05 | GA | MEDICAID | 100002656E | 05 | GA | MEDICAID | 326989 | 01 | GA | WELLCARE | OTHER | P00202126 | 01 | RAILROAD MEDICARE | OTHER |