Provider Demographics
NPI:1801909650
Name:SLACK, DARRYL SPENCER (PA-C)
Entity type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:SPENCER
Last Name:SLACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12911 CLOPPER RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-4811
Mailing Address - Country:US
Mailing Address - Phone:240-527-4378
Mailing Address - Fax:240-313-9601
Practice Address - Street 1:11110 MEDICAL CAMPUS ROAD, SUITE 147
Practice Address - Street 2:MERITUS HEALTH SYSTEM
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:240-313-9600
Practice Address - Fax:240-313-9601
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000715363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0000715OtherSTATE LICENSE #
P8477Medicare UPIN