Provider Demographics
NPI:1871136978
Name:MACDONALD, KATELYN ELYSE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:ELYSE
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KATELYN
Other - Middle Name:ELYSE
Other - Last Name:MARQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-466-5359
Practice Address - Street 1:808 CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4168
Practice Address - Country:US
Practice Address - Phone:208-459-1025
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant