Provider Demographics
NPI:1407814247
Name:MACDONELL, STUART J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STUART
Middle Name:J
Last Name:MACDONELL
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 1:6399 SAN IGNACIO AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1215
Mailing Address - Country:US
Mailing Address - Phone:408-369-5620
Mailing Address - Fax:
Practice Address - Street 1:204 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3135
Practice Address - Country:US
Practice Address - Phone:831-728-2005
Practice Address - Fax:831-728-3310
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103850363AM0700X
CA54521363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2759890Medicare ID - Type Unspecified