Provider Demographics
NPI:1720334410
Name:MCQUEENEY, MICHAEL THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:MCQUEENEY
Suffix:
Gender:M
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 1:514 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:ND
Mailing Address - Zip Code:58367-7220
Mailing Address - Country:US
Mailing Address - Phone:732-277-5330
Mailing Address - Fax:
Practice Address - Street 1:114 3RD ST NE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:ND
Practice Address - Zip Code:58367-7137
Practice Address - Country:US
Practice Address - Phone:701-477-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0491363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical