Healthcare Provider Details

I. General information

NPI: 1811529761
Provider Name (Legal Business Name): CONNOR NORMAN PT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2020
Last Update Date: 02/09/2020
Certification Date: 02/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SELIG CIR
ATHENS GA
30602-1501
US

IV. Provider business mailing address

1167 COLD TREE CT
WATKINSVILLE GA
30677-2367
US

V. Phone/Fax

Practice location:
  • Phone: 706-542-9060
  • Fax:
Mailing address:
  • Phone: 678-612-1790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT013147
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: