Provider Demographics
NPI:1699226753
Name:DONNELLY, DAVID (ATC, PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:ATC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 RED BANK RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-2172
Mailing Address - Country:US
Mailing Address - Phone:513-791-5200
Mailing Address - Fax:513-791-5229
Practice Address - Street 1:4460 RED BANK RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227
Practice Address - Country:US
Practice Address - Phone:513-791-5200
Practice Address - Fax:513-791-5229
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004896RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant