Healthcare Provider Details

I. General information

NPI: 1417384173
Provider Name (Legal Business Name): CHRISTOPHER THOMAS DONOHUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 06/28/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 MINEOLA BLVD FL 2
MINEOLA NY
11501-3959
US

IV. Provider business mailing address

134 MINEOLA BLVD FL 2
MINEOLA NY
11501-3959
US

V. Phone/Fax

Practice location:
  • Phone: 516-294-9363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: