Basic Information
| Provider Information | |||||||||
| NPI: | 1740232966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | SIDE | ||||||||
| MiddleName: | MITCHELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 DARRINGTON DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275138158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198523999 | ||||||||
| FaxNumber: | 9193789114 | ||||||||
| Practice Location | |||||||||
| Address1: | 1309 LEES CHAPEL RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274552601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362865505 | ||||||||
| FaxNumber: | 3362882900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1000323 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-00323 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1740232966 | 05 | NC | MEDICAID |