Provider Demographics
NPI:1619445228
Name:MACK, KAMRYN ALICE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAMRYN
Middle Name:ALICE
Last Name:MACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22255 GREENFIELD RD STE 400
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3734
Mailing Address - Country:US
Mailing Address - Phone:248-849-4880
Mailing Address - Fax:248-849-4881
Practice Address - Street 1:22255 GREENFIELD RD STE 400
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3734
Practice Address - Country:US
Practice Address - Phone:248-849-4880
Practice Address - Fax:248-849-4881
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601009636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant