MEDICARE: DELOYN L MCDONOUGH 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	363A00000X	Physician Assistant	0121	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487662672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DELOYN L MCDONOUGH PA-C

Provider Business Mailing Address
First Line	:	PO BOX 15
Second Line	:
City	:	CHARLESTON
State	:	TN
Zip	:	37310
Country	:	US
Telephone Number	:	423-665-3666
Fax Number	:	423-584-6747

Provider Business Practice Location Address
First Line	:	9026 HIWASSEE STREET NE
Second Line	:
City	:	CHARLESTON
State	:	TN
Zip	:	37310
Country	:	US
Telephone Number	:	423-665-3666
Fax Number	:	423-584-6747

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

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	08/02/2023

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