Healthcare Provider Details

I. General information

NPI: 1235642497
Provider Name (Legal Business Name): MICHAEL EUGENE CONNER III RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

1008 S ELLISON AVE
EL RENO OK
73036-5322
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-5607
  • Fax:
Mailing address:
  • Phone: 405-200-9579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number28283
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number126799
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: