Provider Demographics
NPI:1013953785
Name:MCDONALD, MICHAEL J (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:230 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-1838
Mailing Address - Country:US
Mailing Address - Phone:413-789-6800
Mailing Address - Fax:413-789-5171
Practice Address - Street 1:230 MAIN ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-1838
Practice Address - Country:US
Practice Address - Phone:413-789-6800
Practice Address - Fax:413-789-5171
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA917363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS55881Medicare UPIN
MAAP0834Medicare ID - Type Unspecified