Provider Demographics
NPI:1013368828
Name:MCDONOUGH, TALIA FRANCESCA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:FRANCESCA MARIE
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6647
Mailing Address - Country:US
Mailing Address - Phone:910-662-8440
Mailing Address - Fax:910-662-8474
Practice Address - Street 1:1988 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6647
Practice Address - Country:US
Practice Address - Phone:910-662-8440
Practice Address - Fax:910-795-4826
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant