Healthcare Provider Details

I. General information

NPI: 1619965548
Provider Name (Legal Business Name): PATRICK WELLINGTON CONNELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PATRICK WELLINGTON CONNELLY MD

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 S SUTTER DR SUITE 11
SHOW LOW AZ
85901-8050
US

IV. Provider business mailing address

5300 S SUTTER DR SUITE 11
SHOW LOW AZ
85901-8050
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-9844
  • Fax: 928-537-4437
Mailing address:
  • Phone: 928-537-9844
  • Fax: 928-537-4437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number34632
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: