Healthcare Provider Details

I. General information

NPI: 1861302549
Provider Name (Legal Business Name): CONNOR M WHITNEY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 MISSOURI BLVD
GRAVOIS MILLS MO
65037-5394
US

IV. Provider business mailing address

2396 WILLOW CREEK RD
CAMDENTON MO
65020-6848
US

V. Phone/Fax

Practice location:
  • Phone: 573-374-8885
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2026043306
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: