Healthcare Provider Details

I. General information

NPI: 1245453885
Provider Name (Legal Business Name): NANCY ANN MCDONALD PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 E GRAND AVE STUDENT HEALTH CENTER MAILCODE 6740
CARBONDALE IL
62901
US

IV. Provider business mailing address

374 E GRAND AVE STUDENT HEALTH CENTER BUILDING # 0269
CARBONDALE IL
62901
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-3311
  • Fax: 618-453-4479
Mailing address:
  • Phone: 618-453-3311
  • Fax: 618-453-4479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: