Provider Demographics
NPI:1891717039
Name:MCDONALD, MEREDITH L (PA-C)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:L
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2368
Mailing Address - Country:US
Mailing Address - Phone:231-935-0788
Mailing Address - Fax:231-935-0787
Practice Address - Street 1:1225 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2368
Practice Address - Country:US
Practice Address - Phone:231-935-0788
Practice Address - Fax:231-935-0787
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004630363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN97050002Medicare ID - Type Unspecified
MIQ54104Medicare UPIN