Michael Keene Demack, PA C S

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

6422 Issued in AZ

Practice address

806 S Ponderosa St
Payson, AZ 85541-5541

Phone

(928) 468-8603

Fax

(928) 468-8625

NPI assigned

Feb 27, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in AZ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://fhir4.healow.com/fhir/r4/CEIBDA

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Ponderosa Family Care, LLC

  • Internal Medicine Physician
  • Payson, AZ
  • NPI 1144535626

  AZ

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172534400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1492560000000",
    "number": "1043347313",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2901",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855472901",
            "telephone_number": "928-468-8603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "806 S PONDEROSA ST",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855415541",
            "telephone_number": "928-468-8603",
            "fax_number": "928-468-8625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DEMACK",
        "first_name": "MICHAEL",
        "middle_name": "KEENE",
        "name_prefix": "Mr.",
        "credential": "PA C S",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-02-27",
        "last_updated": "2017-04-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CA",
            "license": "PA 14934",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "AZ",
            "license": "6422",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Cindy Lee Croy, RDH
• Cynthia D. Booth, MD PLLC
• Dan Nurse Practitioner Services, LLC
• Michael D Darnell, DO
• Lori Lynn Davenport, LPC
• Derek R Sloan DDS PLLC
• Desert Dentistry, PLLC
• Dexter D Dewitt, MD
• Diana L Easton
• Ryan L Diquattro

• All providers in Payson, AZ
• Medical Physician Assistant in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 19, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.