Provider Demographics
NPI:1164564811
Name:PACK, JAMES WALTER (PA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:WALTER
Last Name:PACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 OAKWILDE CT.
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108
Mailing Address - Country:US
Mailing Address - Phone:410-987-9110
Mailing Address - Fax:
Practice Address - Street 1:750 OAKWILDE CT
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1447
Practice Address - Country:US
Practice Address - Phone:410-987-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001314363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical