Healthcare Provider Details

I. General information

NPI: 1699260737
Provider Name (Legal Business Name): KEVIN CONNOLLY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 KENNEDY DR
PUTNAM CT
06260-1939
US

IV. Provider business mailing address

22 BERKSHIRE DR
EAST HAMPTON CT
06424-1307
US

V. Phone/Fax

Practice location:
  • Phone: 860-963-3883
  • Fax: 860-928-8299
Mailing address:
  • Phone: 860-841-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: