Provider Demographics
NPI:1275766016
Name:PAYANT MCKENNA, MAUREEN CLEARY (MD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:CLEARY
Last Name:PAYANT MCKENNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 IRVINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3413
Mailing Address - Country:US
Mailing Address - Phone:608-381-7799
Mailing Address - Fax:
Practice Address - Street 1:3033 IRVINGTON WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-3413
Practice Address - Country:US
Practice Address - Phone:608-381-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57653207P00000X
WI5624820207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN020003063Medicare PIN