Provider Demographics
NPI:1366629313
Name:MCDONALD, AMY RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RENEE
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:RENEE
Other - Last Name:WAIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 5865
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-5865
Mailing Address - Country:US
Mailing Address - Phone:806-743-2898
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:602 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415
Practice Address - Country:US
Practice Address - Phone:806-775-8600
Practice Address - Fax:806-775-8602
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K5884Medicare PIN