Provider Demographics
NPI:1497723506
Name:MACK, PAUL D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:D
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 1:8378 E JAMISON CIR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-2752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S JACKSON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-3176
Practice Address - Country:US
Practice Address - Phone:303-321-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COS81757Medicare UPIN