Provider Demographics
NPI:1336341551
Name:DONNELLY, MATTHEW F (PAC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:F
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152974
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33915-2974
Mailing Address - Country:US
Mailing Address - Phone:239-223-0039
Mailing Address - Fax:866-582-5875
Practice Address - Street 1:2804 DEL PRADO BLVD S STE 109
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7283
Practice Address - Country:US
Practice Address - Phone:239-223-0039
Practice Address - Fax:866-582-5875
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292761600Medicaid
FLAF506ZMedicare PIN
FL292761600Medicaid