Provider Demographics
NPI:1184850372
Name:MCNALLY, EDMUND (PA)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:
Last Name:MCNALLY
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 1:301 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5619
Mailing Address - Country:US
Mailing Address - Phone:505-278-8575
Mailing Address - Fax:505-787-2399
Practice Address - Street 1:301 S LAKE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5619
Practice Address - Country:US
Practice Address - Phone:505-278-8575
Practice Address - Fax:505-787-2399
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-PA04363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant