=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598286056
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD PAUL MACK JR. PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2017
-----------------------------------------------------
Last Update Date | 07/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1225 WARM SPRINGS AVE
-----------------------------------------------------
City | HUNTINGDON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16652-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-643-2290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 533 MARJORIE MAE ST
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16803-1683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-788-3782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | MA059100
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------