Provider Demographics
NPI:1063979128
Name:MACK, BRIAN (FNP-C)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 QUINCEMOOR CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-7789
Mailing Address - Country:US
Mailing Address - Phone:336-840-8338
Mailing Address - Fax:
Practice Address - Street 1:655 MONTGOMERY ST STE 810
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94111-2677
Practice Address - Country:US
Practice Address - Phone:844-847-8216
Practice Address - Fax:415-520-9150
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011498207RP1001X, 207RS0012X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care