Provider Demographics
NPI:1285296137
Name:MACK, NATHANIEL DAVID (PA-C)
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:DAVID
Last Name:MACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MAGNOLIA CIRCILE, BLDG. 1465
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32403-5604
Mailing Address - Country:US
Mailing Address - Phone:850-286-7576
Mailing Address - Fax:
Practice Address - Street 1:340 MAGNOLIA CIR BLDG 1465
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32403-5604
Practice Address - Country:US
Practice Address - Phone:850-283-7576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1285296137363A00000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider