Provider Demographics
NPI:1316919236
Name:MCDONOUGH, OWEN EDMOND JR (PA)
Entity type:Individual
Prefix:MR
First Name:OWEN
Middle Name:EDMOND
Last Name:MCDONOUGH
Suffix:JR
Gender:M
Credentials:PA
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Mailing Address - Street 1:2908 CIRCLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5760
Mailing Address - Country:US
Mailing Address - Phone:904-993-7726
Mailing Address - Fax:
Practice Address - Street 1:9826 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5438
Practice Address - Country:US
Practice Address - Phone:904-262-9444
Practice Address - Fax:904-292-2285
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2010-11-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9103012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP92674Medicare UPIN