Provider Demographics
NPI:1073685731
Name:MCDONALD, WALTER ALAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:ALAN
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16280 INDIAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-7017
Mailing Address - Country:US
Mailing Address - Phone:618-885-5548
Mailing Address - Fax:
Practice Address - Street 1:400 N CALDWELL ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:IL
Practice Address - Zip Code:62088-1423
Practice Address - Country:US
Practice Address - Phone:618-635-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002824367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209002824OtherC.R.N.A. LICENSE NUMBER