Healthcare Provider Details

I. General information

NPI: 1295246114
Provider Name (Legal Business Name): KATHLEEN CONNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 CHICAGO AVENUE SOUTH STE 300
MINNEAPOLIS MN
55407
US

IV. Provider business mailing address

3433 BROADWAY ST NE STE 115
MINNEAPOLIS MN
55413-1759
US

V. Phone/Fax

Practice location:
  • Phone: 651-225-7855
  • Fax: 651-312-1570
Mailing address:
  • Phone: 651-312-1505
  • Fax: 612-248-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12595
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: