Healthcare Provider Details

I. General information

NPI: 1396729455
Provider Name (Legal Business Name): RICHARD E DONNELLY P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 W. WHITE MOUNTAIN BLVD
LAKESIDE AZ
85929-7002
US

IV. Provider business mailing address

43 W WHITE MOUNTAIN BLVD
LAKESIDE AZ
85929-7002
US

V. Phone/Fax

Practice location:
  • Phone: 928-367-4040
  • Fax: 928-367-4042
Mailing address:
  • Phone: 928-367-4040
  • Fax: 928-367-4042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1105
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10186
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: