Healthcare Provider Details

I. General information

NPI: 1861092777
Provider Name (Legal Business Name): MR. ANTHONY DARRYL CONNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 W HAYDEN PARK RD
SAN TAN VALLEY AZ
85143-6079
US

IV. Provider business mailing address

127 W HAYDEN PARK RD
SAN TAN VALLEY AZ
85143-6079
US

V. Phone/Fax

Practice location:
  • Phone: 623-565-2716
  • Fax:
Mailing address:
  • Phone: 623-565-2716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: