Healthcare Provider Details

I. General information

NPI: 1295866044
Provider Name (Legal Business Name): BARBARA ANN MACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N K ST
TACOMA WA
98403-1623
US

IV. Provider business mailing address

223 N K ST
TACOMA WA
98403-1623
US

V. Phone/Fax

Practice location:
  • Phone: 253-572-4115
  • Fax:
Mailing address:
  • Phone: 253-572-4115
  • Fax: 253-572-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number34388
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: