Healthcare Provider Details

I. General information

NPI: 1679279012
Provider Name (Legal Business Name): CONNOR LEWELLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7243 DELLA DR FL 3
ORLANDO FL
32819-5104
US

IV. Provider business mailing address

7243 DELLA DR
ORLANDO FL
32819-5104
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-5851
  • Fax: 321-842-0089
Mailing address:
  • Phone: 321-842-5851
  • Fax: 321-842-0089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9117576
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: