Provider Demographics
NPI:1174718498
Name:DONOGHUE, COURTNEY (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DONOGHUE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:DONOGHUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 COMMERCE DR STE 500
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8736
Mailing Address - Country:US
Mailing Address - Phone:847-698-0600
Mailing Address - Fax:847-698-0601
Practice Address - Street 1:4405 WEAVER PKWY
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3269
Practice Address - Country:US
Practice Address - Phone:630-352-5350
Practice Address - Fax:630-352-5349
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
085.001814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.001814OtherSTATE LICENSE