Healthcare Provider Details

I. General information

NPI: 1598408262
Provider Name (Legal Business Name): CONNOR PASSALACQUA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8423 MARKET ST STE 207
BOARDMAN OH
44512-6778
US

IV. Provider business mailing address

966 BARTLEY ST
JASPER IN
47546-2641
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-8700
  • Fax:
Mailing address:
  • Phone: 812-996-7810
  • Fax: 812-996-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: