Provider Demographics
NPI:1467665430
Name:DONAHUE, DENISE (PA)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2521
Mailing Address - Country:US
Mailing Address - Phone:310-547-0202
Mailing Address - Fax:310-547-5096
Practice Address - Street 1:593 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2521
Practice Address - Country:US
Practice Address - Phone:310-547-0202
Practice Address - Fax:310-547-5096
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant