Provider Demographics
NPI:1164646857
Name:INNES, DONALD T (PA)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:T
Last Name:INNES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N MALACATE ST
Mailing Address - Street 2:
Mailing Address - City:AJO
Mailing Address - State:AZ
Mailing Address - Zip Code:85321-2254
Mailing Address - Country:US
Mailing Address - Phone:520-387-5651
Mailing Address - Fax:
Practice Address - Street 1:410 N MALACATE ST
Practice Address - Street 2:
Practice Address - City:AJO
Practice Address - State:AZ
Practice Address - Zip Code:85321-2254
Practice Address - Country:US
Practice Address - Phone:520-387-5651
Practice Address - Fax:520-387-5347
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant