Provider Demographics
NPI:1790740900
Name:O'DONNELL, BRIAN D (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11130 E CHOLLA ST BLDG 1
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-3922
Mailing Address - Country:US
Mailing Address - Phone:480-882-7520
Mailing Address - Fax:
Practice Address - Street 1:2 EMBARCADERO CTR LBBY LEVEL
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94111-3823
Practice Address - Country:US
Practice Address - Phone:415-578-3100
Practice Address - Fax:617-421-6084
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA988363A00000X, 363AM0700X
CA51380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1577Medicare ID - Type Unspecified
MAS88177Medicare UPIN