Provider Demographics
NPI:1972186146
Name:DONOVAN, MATTHEW JAMES
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 WINFORD WAY
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-4030
Mailing Address - Country:US
Mailing Address - Phone:781-570-6067
Mailing Address - Fax:
Practice Address - Street 1:103 GARLAND ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5066
Practice Address - Country:US
Practice Address - Phone:617-389-6270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA8320OtherBOARD OF REGISTRATION OF PHYSICIAN ASSISTANTS