Provider Demographics
NPI:1669643250
Name:MACK, SHIRLEY A
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:A
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8486 S HUNNIC DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85747-5989
Mailing Address - Country:US
Mailing Address - Phone:520-777-8686
Mailing Address - Fax:
Practice Address - Street 1:8486 S HUNNIC DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85747-5989
Practice Address - Country:US
Practice Address - Phone:520-777-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ460924171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ460924OtherLICENSING CERTIFICATION