Provider Demographics
NPI:1972516359
Name:MCDONALD, KELLY L (PA)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:L
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:903 5TH ST # C
Mailing Address - Street 2:
Mailing Address - City:ESTANCIA
Mailing Address - State:NM
Mailing Address - Zip Code:87016-1155
Mailing Address - Country:US
Mailing Address - Phone:505-384-2777
Mailing Address - Fax:505-384-2204
Practice Address - Street 1:903 5TH ST # C
Practice Address - Street 2:
Practice Address - City:ESTANCIA
Practice Address - State:NM
Practice Address - Zip Code:87016-1155
Practice Address - Country:US
Practice Address - Phone:505-384-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2372255A2300X
NMPA2013-0057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer