Provider Demographics
NPI:1790817872
Name:PACK, ANTHONY J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:J
Last Name:PACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-2554
Mailing Address - Country:US
Mailing Address - Phone:215-345-2455
Mailing Address - Fax:215-345-2978
Practice Address - Street 1:595 W STATE ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2554
Practice Address - Country:US
Practice Address - Phone:215-345-2455
Practice Address - Fax:215-345-2978
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002856L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS70670Medicare UPIN
PA096232K3HMedicare ID - Type Unspecified