Provider Demographics
NPI:1235207366
Name:MACK, CAROL JEAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:JEAN
Last Name:MACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 NORRIS CT SW
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-4361
Mailing Address - Country:US
Mailing Address - Phone:703-669-9343
Mailing Address - Fax:
Practice Address - Street 1:1850 M ST NW
Practice Address - Street 2:SUITE 450
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-5803
Practice Address - Country:US
Practice Address - Phone:202-293-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA30161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCPA30161OtherSTATE LICENSE