Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QS0010X | Family Doctor - Sports Medicine | 50910 | MN |
Y | 207QS0010X | Family Doctor - Sports Medicine | 54869 | WI |
NPI | 1225151558 |
---|---|
Provider Name | Patrick Earl Mcdonough |
First Address | St. Croix Falls, WI 54024 |
Second Address | St. Croix Falls, WI 54024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2007 |
Last Update Date | 15/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1225151558 | (05) | MN |
1225151558 | (05) | WI |