Provider Demographics
NPI:1518324904
Name:MACDONALD, RYAN LEIGH (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:LEIGH
Last Name:MACDONALD
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 1:3640 MAIN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1145
Mailing Address - Country:US
Mailing Address - Phone:413-732-4242
Mailing Address - Fax:
Practice Address - Street 1:3640 MAIN ST
Practice Address - Street 2:SUITE 302
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1145
Practice Address - Country:US
Practice Address - Phone:413-732-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5484363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical