Provider Demographics
NPI:1568658045
Name:MCDONOUGH, DENA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:DENA
Middle Name:LYNN
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4872
Mailing Address - Country:US
Mailing Address - Phone:646-797-8880
Mailing Address - Fax:646-797-8966
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:646-797-8880
Practice Address - Fax:646-797-8966
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007168363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical