Provider Demographics
NPI:1972841419
Name:DONAHUE, PATRICIA EDWARDS (PA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:EDWARDS
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:EILEEN
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-288-4329
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-288-4329
Practice Address - Fax:601-288-3191
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04804742Medicaid