Provider Demographics
NPI:1487662672
Name:MCDONOUGH, DELOYN L (PA-C)
Entity Type:Individual
Prefix:
First Name:DELOYN
Middle Name:L
Last Name:MCDONOUGH
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 15
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:TN
Mailing Address - Zip Code:37310
Mailing Address - Country:US
Mailing Address - Phone:423-665-3666
Mailing Address - Fax:423-584-6747
Practice Address - Street 1:9026 HIWASSEE STREET NE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:TN
Practice Address - Zip Code:37310
Practice Address - Country:US
Practice Address - Phone:423-665-3666
Practice Address - Fax:423-584-6747
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512988Medicaid