Provider Demographics
NPI:1649335233
Name:MACK, JOEL D (NP)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:D
Last Name:MACK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7655
Mailing Address - Country:US
Mailing Address - Phone:214-470-3174
Mailing Address - Fax:
Practice Address - Street 1:3515 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503
Practice Address - Country:US
Practice Address - Phone:903-791-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618334363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP28413Medicare UPIN