Provider Demographics
NPI:1295346104
Name:DONOGHUE, JUSTIN DANIEL
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DANIEL
Last Name:DONOGHUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 HUGHEY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-2115
Mailing Address - Country:US
Mailing Address - Phone:989-280-3799
Mailing Address - Fax:
Practice Address - Street 1:71 HUGHEY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-2115
Practice Address - Country:US
Practice Address - Phone:989-280-3799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313630363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704313630Medicaid