Provider Demographics
NPI:1245758234
Name:MACH, JAMES ALAN JR
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALAN
Last Name:MACH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40668 LAKELAND RD
Mailing Address - Street 2:
Mailing Address - City:STURGEON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55783-3868
Mailing Address - Country:US
Mailing Address - Phone:218-251-8272
Mailing Address - Fax:
Practice Address - Street 1:4572 COUNTY ROAD 61
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9401
Practice Address - Country:US
Practice Address - Phone:218-485-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116704367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered