Provider Demographics
NPI:1689852410
Name:MCDONALD, KEVIN RYAN (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RYAN
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HUNT LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-2433
Mailing Address - Country:US
Mailing Address - Phone:732-778-5516
Mailing Address - Fax:
Practice Address - Street 1:425 POST RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6232
Practice Address - Country:US
Practice Address - Phone:203-259-7442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00159800363A00000X
MDC0003922363A00000X
CAPA18705363AM0700X
MO2012007333363AM0700X
CT23.002924363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant