Healthcare Provider Details

I. General information

NPI: 1477492635
Provider Name (Legal Business Name): IAN MCDONNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S WASHINGTON AVE
SCRANTON PA
18505-3814
US

IV. Provider business mailing address

1518 PINE ST
SCRANTON PA
18510-1964
US

V. Phone/Fax

Practice location:
  • Phone: 570-941-0630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: