Healthcare Provider Details

I. General information

NPI: 1639132129
Provider Name (Legal Business Name): ANDREW DONN CONKLE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 E STATE ST SUITE 400
COLUMBUS OH
43215-4354
US

IV. Provider business mailing address

5400 FRANTZ RD SUITE 250
DUBLIN OH
43016-4144
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-7370
  • Fax:
Mailing address:
  • Phone: 614-544-6356
  • Fax: 614-544-6370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.001081
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: