Provider Demographics
NPI:1821184656
Name:DONNELLY, SUSAN L (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:DONNELLY
Suffix:
Gender:F
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:PO BOX 40000
Mailing Address - Street 2:DEPT 634 HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06151-0001
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:HARTFORD HOSPITAL ORTHOPEDICS DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-545-2245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000935363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003009354Medicaid
CT970001280Medicare ID - Type UnspecifiedFOR CLINIC 00814
CT003009354Medicaid