Healthcare Provider Details

I. General information

NPI: 1073381869
Provider Name (Legal Business Name): CONNOR PATRICK LEBSACK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4483 DUNCAN AVE
SAINT LOUIS MO
63110-1111
US

IV. Provider business mailing address

916 FAIRDALE AVE
SAINT LOUIS MO
63119-1222
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-7055
  • Fax:
Mailing address:
  • Phone: 314-625-1608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: