Provider Demographics
NPI:1700418175
Name:MCDONOUGH, SEAN M (PA)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:M
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:8100 INNOVATION PARK DR # 110
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4870
Practice Address - Country:US
Practice Address - Phone:703-970-6464
Practice Address - Fax:571-414-6941
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110007777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program