Provider Demographics
NPI:1346356359
Name:MACK, RANDALL (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:MACK
Suffix:
Gender:M
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 1:10 KRUGER ROAD
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:MT
Mailing Address - Zip Code:59859
Mailing Address - Country:US
Mailing Address - Phone:406-826-4800
Mailing Address - Fax:
Practice Address - Street 1:10 KRUGER ROAD
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:MT
Practice Address - Zip Code:59859
Practice Address - Country:US
Practice Address - Phone:406-826-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60595202363A00000X
MTMED-PAC-LIC-190363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1346356359Medicaid
WAP01684706OtherRR MEDICARE WVH
WA1346356359Medicaid