Provider Demographics
NPI:1578815759
Name:DONNELLY, MEGAN MARIE (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5901 STEILACOOM BLVD SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3120
Mailing Address - Country:US
Mailing Address - Phone:253-572-2856
Mailing Address - Fax:
Practice Address - Street 1:4245 ROOSEVELT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6008
Practice Address - Country:US
Practice Address - Phone:206-598-4288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60314307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1578815759Medicaid