Provider Demographics
NPI:1023406725
Name:DONAHUE, IAN JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:JOSEPH
Last Name:DONAHUE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1310 SAN BERNARDINO RD
Mailing Address - Street 2:STE. 103
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4979
Mailing Address - Country:US
Mailing Address - Phone:909-920-0444
Mailing Address - Fax:909-920-5044
Practice Address - Street 1:1310 SAN BERNARDINO RD
Practice Address - Street 2:STE. 103
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4979
Practice Address - Country:US
Practice Address - Phone:909-920-0444
Practice Address - Fax:909-920-5044
Is Sole Proprietor?:No
Enumeration Date:2015-01-03
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA51838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant