Healthcare Provider Details

I. General information

NPI: 1083995609
Provider Name (Legal Business Name): TIMOTHY R DONNELLY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 5TH AVE SUITE 100
SAN DIEGO CA
92101-3291
US

IV. Provider business mailing address

12285 SCRIPPS POWAY PKWY
POWAY CA
92064-6149
US

V. Phone/Fax

Practice location:
  • Phone: 619-461-3717
  • Fax: 619-461-5663
Mailing address:
  • Phone: 951-708-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA12169
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: