Provider Demographics
NPI:1801973615
Name:MACK, CHARISSE L (PA)
Entity type:Individual
Prefix:
First Name:CHARISSE
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-367-2968
Practice Address - Street 1:6140 CURTISIAN AVE
Practice Address - Street 2:STE 400
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8880
Practice Address - Country:US
Practice Address - Phone:208-367-3500
Practice Address - Fax:208-367-2968
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-632363A00000X
IDPA632363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0214786OtherSTATE OF WA DOL
IDPAD65OtherBLUE CROSS OF ID
ID000010158697OtherBLUE SHIELD OF ID
ID807590500Medicaid
IDQ76267Medicare UPIN
ID807590500Medicaid
P00465610Medicare PIN