Healthcare Provider Details

I. General information

NPI: 1558658062
Provider Name (Legal Business Name): MICAH DANIEL MCDONALD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 SAM PERRY BLVD STE 318
FREDERICKSBURG VA
22401-4466
US

IV. Provider business mailing address

1340 CENTRAL PARK BLVD STE 100
FREDERICKSBURG VA
22401-4940
US

V. Phone/Fax

Practice location:
  • Phone: 540-372-7792
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006139
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: