Healthcare Provider Details

I. General information

NPI: 1497865323
Provider Name (Legal Business Name): ELIZABETH A. MCDONOUGH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH A. BETHEA PA-C

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 CROSSPOINTE DRIVE
NAPLES FL
34110-0930
US

IV. Provider business mailing address

15051 S. TAMIAMI TRAIL SUITE 203
FORT MYERS FL
33908
US

V. Phone/Fax

Practice location:
  • Phone: 239-596-9075
  • Fax: 239-596-9076
Mailing address:
  • Phone: 239-437-8810
  • Fax: 239-313-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9103756
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: