Healthcare Provider Details

I. General information

NPI: 1144894734
Provider Name (Legal Business Name): COLLIN CONNOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 W 4TH ST
HOLTON KS
66436-1153
US

IV. Provider business mailing address

1010 N KANSAS ST
WICHITA KS
67214-3124
US

V. Phone/Fax

Practice location:
  • Phone: 785-364-3205
  • Fax: 785-364-3468
Mailing address:
  • Phone: 316-293-2665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94-10492
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0449543
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: