Provider Demographics
NPI:1487763603
Name:MCDONALD, KATHLEEN A (PA)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2740
Mailing Address - Country:US
Mailing Address - Phone:505-747-4144
Mailing Address - Fax:505-747-3213
Practice Address - Street 1:1009 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2740
Practice Address - Country:US
Practice Address - Phone:505-747-4144
Practice Address - Fax:505-747-3213
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2003-0045363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM67289258Medicaid
NMQ04058Medicare UPIN
NM67289258Medicaid