Provider Demographics
NPI:1619918968
Name:MACK, JOHN EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:MACK
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:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-0388
Mailing Address - Country:US
Mailing Address - Phone:540-245-7585
Mailing Address - Fax:
Practice Address - Street 1:70 MEDICAL CENTER CIR STE 213
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2273
Practice Address - Country:US
Practice Address - Phone:540-245-7705
Practice Address - Fax:540-245-7710
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006808363AS0400X
NY006239363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01908396Medicaid
NY01908396Medicaid
NYS73912Medicare UPIN