Healthcare Provider Details

I. General information

NPI: 1013953785
Provider Name (Legal Business Name): MICHAEL J MCDONALD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 MAIN ST
AGAWAM MA
01001-1838
US

IV. Provider business mailing address

230 MAIN ST
AGAWAM MA
01001-1838
US

V. Phone/Fax

Practice location:
  • Phone: 413-789-6800
  • Fax: 413-789-5171
Mailing address:
  • Phone: 413-789-6800
  • Fax: 413-789-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number917
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: