Provider Demographics
NPI:1639837784
Name:MCDONALD, ETHAN WESLEY I
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:WESLEY
Last Name:MCDONALD
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MACALLAN LN UNIT 1
Mailing Address - Street 2:
Mailing Address - City:TRIADELPHIA
Mailing Address - State:WV
Mailing Address - Zip Code:26059-2464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 MEDICAL PARK STE 104
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6389
Practice Address - Country:US
Practice Address - Phone:304-242-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV2647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program