Provider Demographics
NPI:1316647845
Name:MCDONALD, PHILLIP BRUCE (NP)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BRUCE
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:80 5TH AVE OFC 903-10
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8002
Mailing Address - Country:US
Mailing Address - Phone:347-886-1088
Mailing Address - Fax:
Practice Address - Street 1:80 5TH AVE OFC 903-10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8002
Practice Address - Country:US
Practice Address - Phone:347-886-1088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404321363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty