Basic Information
| Provider Information | |||||||||
| NPI: | 1619918968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388 | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229390388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402457585 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 70 MEDICAL CENTER CIR STE 213 | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229392273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402457705 | ||||||||
| FaxNumber: | 5402457710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 006239 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 006239 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 0110006808 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 01908396 | 05 | NY | MEDICAID |