Healthcare Provider Details

I. General information

NPI: 1831735851
Provider Name (Legal Business Name): CONNOR PATRICK DOHERTY PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 LAFAYETTE RD STE 200
INDIANAPOLIS IN
46222-1147
US

IV. Provider business mailing address

3400 LAFAYETTE RD STE 200
INDIANAPOLIS IN
46222-1147
US

V. Phone/Fax

Practice location:
  • Phone: 317-291-7422
  • Fax: 317-291-7433
Mailing address:
  • Phone: 317-291-7422
  • Fax: 317-291-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096004117
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: