Healthcare Provider Details

I. General information

NPI: 1639837784
Provider Name (Legal Business Name): ETHAN WESLEY MCDONALD I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MEDICAL PARK STE 104
WHEELING WV
26003-6389
US

IV. Provider business mailing address

206 MACALLAN LN UNIT 1
TRIADELPHIA WV
26059-2464
US

V. Phone/Fax

Practice location:
  • Phone: 304-242-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2647
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: