Provider Demographics
NPI:1346351194
Name:PACK, STEVEN HENRY (PA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:HENRY
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 1:706 CADET CT
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2649
Mailing Address - Country:US
Mailing Address - Phone:615-449-2472
Mailing Address - Fax:615-449-4709
Practice Address - Street 1:706 CADET CT
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2649
Practice Address - Country:US
Practice Address - Phone:615-449-2472
Practice Address - Fax:615-449-4709
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3662285Medicaid
TN3662285Medicare ID - Type Unspecified
TN3662285Medicaid