Basic Information
| Provider Information | |||||||||
| NPI: | 1639275118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZILCOSKY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FREEMAN | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862544000 | ||||||||
| FaxNumber: | 3862264577 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 STATE ROAD 44 | ||||||||
| Address2: | |||||||||
| City: | NEW SMYRNA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321687271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864285554 | ||||||||
| FaxNumber: | 3864286291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 09/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA3751 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA3751 | 01 | DC | LICENSE | OTHER |