Healthcare Provider Details

I. General information

NPI: 1245019801
Provider Name (Legal Business Name): ELIJAH CONNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 23RD ST NW
WASHINGTON DC
20037-2342
US

IV. Provider business mailing address

2634 CALVARY RD
BEL AIR MD
21015-6616
US

V. Phone/Fax

Practice location:
  • Phone: 202-715-4000
  • Fax:
Mailing address:
  • Phone: 443-617-1575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA200001813
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: