Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 036-098178 | IL |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 036-098178 | IL |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 72492 | WI |
NPI | 1174574966 |
---|---|
Provider Name | Brian Donahue |
First Address | Hayward, WI 54843-3606 |
Second Address | Hayward, WI 54843-3606 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2006 |
Last Update Date | 11/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036-098178 | (05) | IL |
G82526 | (02) | IL |