Provider Demographics
NPI:1801812342
Name:DONOVAN, NICOLE RENEE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENEE
Last Name:DONOVAN
Suffix:
Gender:F
Credentials: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:PO BOX 198441
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8441
Mailing Address - Country:US
Mailing Address - Phone:813-745-7365
Mailing Address - Fax:813-449-8618
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-7365
Practice Address - Fax:813-449-8618
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291308900Medicaid
FLP00982254OtherRR MEDICARE
FL291308900Medicaid
FLE7635R- PASCOMedicare PIN
FLE7635SMedicare PIN