Provider Demographics
NPI:1245352756
Name:MACK, STEPHEN ALEXANDER (APRN-CNP; PMHNP-C)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ALEXANDER
Last Name:MACK
Suffix:
Gender:M
Credentials:APRN-CNP; PMHNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6107 MUSTANG TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-1121
Mailing Address - Country:US
Mailing Address - Phone:281-773-7267
Mailing Address - Fax:
Practice Address - Street 1:21613 PROVINCIAL BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-6506
Practice Address - Country:US
Practice Address - Phone:713-777-9900
Practice Address - Fax:713-777-9902
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9319111N00000X, 111NR0400X, 111NS0005X
TXAP128914363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner