Provider Demographics
NPI:1750671566
Name:DONOVAN, ROBERT IAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:IAN
Last Name:DONOVAN
Suffix:
Gender:M
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 1:811 MCCABE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-3327
Mailing Address - Country:US
Mailing Address - Phone:302-437-4997
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-0001
Practice Address - Country:US
Practice Address - Phone:302-733-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant