Healthcare Provider Details

I. General information

NPI: 1992575617
Provider Name (Legal Business Name): DOMINIQUE MACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIQUE MACK PA-C

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 SMITH AVE
THOMASVILLE GA
31792-5533
US

IV. Provider business mailing address

334 SMITH AVE
THOMASVILLE GA
31792-5533
US

V. Phone/Fax

Practice location:
  • Phone: 229-227-1595
  • Fax:
Mailing address:
  • Phone: 229-227-1595
  • Fax: 229-227-1385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13682
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: