Provider Demographics
NPI:1740232966
Name:MACK, SIDE MITCHELL JR (PA)
Entity Type:Individual
Prefix:
First Name:SIDE
Middle Name:MITCHELL
Last Name:MACK
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1021 DARRINGTON DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8158
Mailing Address - Country:US
Mailing Address - Phone:919-852-3999
Mailing Address - Fax:919-378-9114
Practice Address - Street 1:1309 LEES CHAPEL RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2601
Practice Address - Country:US
Practice Address - Phone:336-286-5505
Practice Address - Fax:336-288-2900
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1000323363A00000X
NC0010-00323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1740232966Medicaid
NC1740232966Medicaid