Provider Demographics
NPI:1619286200
Name:MCDONOUGH, KRISTIN KATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:KATHERINE
Last Name:MCDONOUGH
Suffix:
Gender:F
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 1:125 WASHINGTON ST APT 302
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-3043
Mailing Address - Country:US
Mailing Address - Phone:336-684-4662
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:203-576-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant