Basic Information
| Provider Information | |||||||||
| NPI: | 1780786053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4185 SENECA STREET | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166748189 | ||||||||
| FaxNumber: | 7167120469 | ||||||||
| Practice Location | |||||||||
| Address1: | 4185 SENECA ST | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142243565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166748189 | ||||||||
| FaxNumber: | 7167120469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 367500000X | 293597-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.