Provider Demographics
NPI:1619367406
Name:DONOHUE, MARY (PHYSCIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DONOHUE
Suffix:
Gender:F
Credentials:PHYSCIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 WOODLAKE WYNDE
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2119
Mailing Address - Country:US
Mailing Address - Phone:516-313-7831
Mailing Address - Fax:
Practice Address - Street 1:27001 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3402
Practice Address - Country:US
Practice Address - Phone:727-475-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-31
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110143363A00000X
NY0167861363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical