Provider Demographics
NPI:1578966008
Name:ZACK, KYRENE M (PA-C)
Entity Type:Individual
Prefix:
First Name:KYRENE
Middle Name:M
Last Name:ZACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KYRENE
Other - Middle Name:M
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:785 5TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-709-6529
Practice Address - Street 1:22 ST PAUL DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-4221
Practice Address - Country:US
Practice Address - Phone:717-217-6870
Practice Address - Fax:717-217-6945
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057195363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103157918 0001Medicaid