Provider Demographics
NPI:1790709954
Name:MACDONALD, LOUELLEN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LOUELLEN
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4868
Mailing Address - Country:US
Mailing Address - Phone:508-746-8977
Mailing Address - Fax:508-746-3364
Practice Address - Street 1:61 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4868
Practice Address - Country:US
Practice Address - Phone:508-746-8977
Practice Address - Fax:508-746-3364
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP2575Medicare ID - Type Unspecified