Provider Demographics
NPI:1366470791
Name:THEODORE, DONNA ANTONIA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:ANTONIA
Last Name:THEODORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7511
Mailing Address - Country:US
Mailing Address - Phone:919-876-7807
Mailing Address - Fax:919-876-8823
Practice Address - Street 1:3604 BUSH ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7511
Practice Address - Country:US
Practice Address - Phone:919-876-7807
Practice Address - Fax:919-876-8823
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104147363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical