Basic Information
| Provider Information | |||||||||
| NPI: | 1679624985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONOVAN | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | PAULINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 FAIRMOUNT AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104947920 | ||||||||
| FaxNumber: | 4109028247 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 FAIRMOUNT AVE STE 500 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104941662 | ||||||||
| FaxNumber: | 4104941718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0002074 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.