Provider Demographics
NPI:1861479479
Name:MCDONALD, MARK C (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
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:S68W15500 JANESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-2613
Mailing Address - Country:US
Mailing Address - Phone:414-422-4000
Mailing Address - Fax:
Practice Address - Street 1:8700 W WATERTOWN PLANK RD
Practice Address - Street 2:ORTHOPAEDIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-805-8602
Practice Address - Fax:414-805-7171
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1305-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41923400Medicaid
WI1861479479Medicaid
WI41923400Medicaid