Provider Demographics
NPI:1023748357
Name:MCDONALD, COLEEN SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:COLEEN
Middle Name:SHANNON
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 1:32 SCHIRRA DR
Mailing Address - Street 2:
Mailing Address - City:WANAQUE
Mailing Address - State:NJ
Mailing Address - Zip Code:07465-1036
Mailing Address - Country:US
Mailing Address - Phone:201-888-9824
Mailing Address - Fax:
Practice Address - Street 1:780 ROUTE 3
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-2328
Practice Address - Country:US
Practice Address - Phone:973-777-6767
Practice Address - Fax:973-777-6745
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00708400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant