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Individual
CHARISSE L MACK
Active
Individual
CHARISSE L MACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-632
ID
363AS0400X
Surgical Physician Assistant
PA632
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010158697
BLUE SHIELD OF ID
ID
01
—
0214786
STATE OF WA DOL
ID
05
—
807590500
—
ID
01
—
PAD65
BLUE CROSS OF ID
ID
Enumeration date
11/01/2006
Last updated
03/04/2013
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