Basic Information
| Provider Information | |||||||||
| NPI: | 1396729455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONNELLY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 W WHITE MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859297002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283674040 | ||||||||
| FaxNumber: | 9283674042 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 W. WHITE MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859297002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283674040 | ||||||||
| FaxNumber: | 9283674042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1105 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 10186 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 86080015085259A253 | 01 | AZ | TRIWEST | OTHER | 558930400 | 05 | MN | MEDICAID | 342254 | 05 | AZ | MEDICAID | 970001299 | 01 | AZ | RAILROAD MEDICARE | OTHER |