Provider Demographics
NPI:1982044616
Name:MACK, STUART G (PA)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:G
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 1:215 N ALLISON AVE
Mailing Address - Street 2:PO BOX 1150
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-1336
Mailing Address - Country:US
Mailing Address - Phone:606-546-9287
Mailing Address - Fax:606-546-9363
Practice Address - Street 1:215 N ALLISON AVE
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1336
Practice Address - Country:US
Practice Address - Phone:606-546-9287
Practice Address - Fax:606-546-9363
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100255350Medicaid
KYCS1631301477OtherHUMANA CARESOURCE