Provider Demographics
NPI:1720325491
Name:MACDONALD, COREY ALLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:ALLEN
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 PILLSBURY ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3556
Mailing Address - Country:US
Mailing Address - Phone:603-224-4776
Mailing Address - Fax:603-228-2113
Practice Address - Street 1:1 PILLSBURY ST
Practice Address - Street 2:SUITE 202
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3556
Practice Address - Country:US
Practice Address - Phone:603-224-4776
Practice Address - Fax:603-228-2113
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MERNA123058367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3100551Medicaid
NHT400208761Medicare UPIN