Provider Demographics
NPI:1912387614
Name:DONNELLY, RONAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RONAN
Middle Name:
Last Name:DONNELLY
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 1:26401 CROWN VALLEY PKWY 101
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6302
Mailing Address - Country:US
Mailing Address - Phone:949-348-4000
Mailing Address - Fax:949-348-1435
Practice Address - Street 1:26401 CROWN VALLEY PKWY 101
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6302
Practice Address - Country:US
Practice Address - Phone:949-348-4000
Practice Address - Fax:949-348-1435
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2015-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52559363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant