Healthcare Provider Details

I. General information

NPI: 1487308557
Provider Name (Legal Business Name): MADELINE JEANNE MCDONALD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 JOHNSON AVE STE 102
SAN LUIS OBISPO CA
93401-4174
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 805-782-8844
  • Fax:
Mailing address:
  • Phone: 858-554-7797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: