Healthcare Provider Details

I. General information

NPI: 1194299503
Provider Name (Legal Business Name): CONNOR ROY CHRISTIE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 19-100
CHICAGO IL
60611-5969
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 19-100
CHICAGO IL
60611-5969
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-3278
  • Fax: 312-695-5774
Mailing address:
  • Phone: 312-664-3278
  • Fax: 312-695-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009051
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: