Provider Demographics
NPI:1225224090
Name:MCDONOUGH, GREGORY R (PA-C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:MCDONOUGH
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 1:820 N. CHELAN AVE.
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2028
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1225224090Medicaid
WAG8920080OtherWVH PTAN
WAG8920081OtherWVH PTAN
WAG8920081OtherWVH PTAN
WAG8868761Medicare PIN