Provider Demographics
NPI:1104470590
Name:MACK, TIMOTHY A (APRN)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:A
Last Name:MACK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5718 WESTHEIMER RD STE 1800
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-5773
Mailing Address - Country:US
Mailing Address - Phone:281-783-8162
Mailing Address - Fax:
Practice Address - Street 1:3725 N LAKELINE BLVD STE C
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-5354
Practice Address - Country:US
Practice Address - Phone:281-783-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142417363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily