Provider Demographics
NPI:1093753592
Name:MACNALLY, DAVID S (PA C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:S
Last Name:MACNALLY
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058
Mailing Address - Country:US
Mailing Address - Phone:541-296-9151
Mailing Address - Fax:541-296-4710
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-296-9151
Practice Address - Fax:541-296-4710
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003246363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218112Medicaid
OR383996Medicare Oscar/Certification
ORR0000WFBCSMedicare PIN
OR218112Medicaid