Healthcare Provider Details

I. General information

NPI: 1750018164
Provider Name (Legal Business Name): CONNOR JAMES RICHARDSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 SE COMBS FLAT RD STE 1200
PRINEVILLE OR
97754-2562
US

IV. Provider business mailing address

PO BOX 6095
BEND OR
97708-6095
US

V. Phone/Fax

Practice location:
  • Phone: 541-447-6263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA221451
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: