MEDICARE: MR. STUART J MACDONELL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	103850	NC
2	363AM0700X	Medical Physician Assistant	54521	CA

General Provider Information

NPI Number	:	1407814247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STUART J MACDONELL PA-C

Provider Business Mailing Address
First Line	:	6399 SAN IGNACIO AVE STE 120
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95119-1215
Country	:	US
Telephone Number	:	408-369-5620
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 GREEN VALLEY RD
Second Line	:
City	:	FREEDOM
State	:	CA
Zip	:	95019-3135
Country	:	US
Telephone Number	:	831-728-2005
Fax Number	:	831-728-3310

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	03/19/2024

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