Provider Demographics
NPI:1043347313
Name:DEMACK, MICHAEL KEENE (PA C S)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KEENE
Last Name:DEMACK
Suffix:
Gender:M
Credentials:PA C S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2901
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85547-2901
Mailing Address - Country:US
Mailing Address - Phone:928-468-8603
Mailing Address - Fax:
Practice Address - Street 1:806 S PONDEROSA ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5541
Practice Address - Country:US
Practice Address - Phone:928-468-8603
Practice Address - Fax:928-468-8625
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14934207Q00000X
AZ6422363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine