Provider Demographics
NPI:1790788016
Name:MCKERNAN, PAUL DUANE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DUANE
Last Name:MCKERNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18699 N 67TH AVE
Mailing Address - Street 2:STE 320
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7143
Mailing Address - Country:US
Mailing Address - Phone:623-561-7250
Mailing Address - Fax:623-561-0098
Practice Address - Street 1:18699 N 67TH AVE
Practice Address - Street 2:STE 320
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7143
Practice Address - Country:US
Practice Address - Phone:623-561-7250
Practice Address - Fax:623-561-0098
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
AZ17534207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ280371Medicaid
AZ280371Medicaid
AZC99958Medicare UPIN