Provider Demographics
NPI:1396729455
Name:DONNELLY, RICHARD E (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
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 1:43 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-7002
Mailing Address - Country:US
Mailing Address - Phone:928-367-4040
Mailing Address - Fax:928-367-4042
Practice Address - Street 1:43 W. WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-7002
Practice Address - Country:US
Practice Address - Phone:928-367-4040
Practice Address - Fax:928-367-4042
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1105363AS0400X
MN10186363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86080015085259A253OtherTRIWEST
MN558930400Medicaid
AZ342254Medicaid
AZ970001299OtherRAILROAD MEDICARE
R10773Medicare UPIN
AZPA1105Medicare ID - Type Unspecified
MN558930400Medicaid
AZ342254Medicaid