Healthcare Provider Details

I. General information

NPI: 1922024926
Provider Name (Legal Business Name): BRIAN KNUDSEN CONNOLLY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8151 ARLINGTON AVE SUITES U-V
RIVERSIDE CA
92503-0436
US

IV. Provider business mailing address

8151 ARLINGTON AVE SUITES U-V
RIVERSIDE CA
92503-0436
US

V. Phone/Fax

Practice location:
  • Phone: 760-728-3816
  • Fax: 760-728-1542
Mailing address:
  • Phone: 760-728-3816
  • Fax: 760-728-1542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number15157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: