Provider Demographics
NPI:1891795175
Name:ODONNELL, JOHN P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
Last Name:ODONNELL
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 1:8622 133RD LN
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-8837
Mailing Address - Country:US
Mailing Address - Phone:386-208-4084
Mailing Address - Fax:386-752-9143
Practice Address - Street 1:173 NW ALBRITTON LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4451
Practice Address - Country:US
Practice Address - Phone:386-755-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant