Individual
RICHARD E DONNELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
P.A.-C.
Contact information
Practice address
43 W. WHITE MOUNTAIN BLVD, LAKESIDE, AZ 85929-7002
(928) 367-4040
(928) 367-4042
Mailing address
43 W WHITE MOUNTAIN BLVD, LAKESIDE, AZ 85929-7002
(928) 367-4040
(928) 367-4042
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
10186
MN
363AS0400X
Surgical Physician Assistant
Primary
1105
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
342254
—
AZ
05
—
558930400
—
MN
01
—
86080015085259A253
TRIWEST
AZ
01
—
970001299
RAILROAD MEDICARE
AZ
Enumeration date
12/02/2005
Last updated
02/16/2011
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