Provider Demographics
NPI:1003325630
Name:MCDONALD, MICHELE RENE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENE
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:RENE
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:4897 VINEGAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:ELBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:13060-9780
Mailing Address - Country:US
Mailing Address - Phone:315-857-3148
Mailing Address - Fax:
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341811363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner