Healthcare Provider Details

I. General information

NPI: 1730465741
Provider Name (Legal Business Name): MACI NICOLE O'CONNOR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1926 ALCOA HWY BLDG F STE 380
KNOXVILLE TN
37920-1524
US

IV. Provider business mailing address

1926 ALCOA HWY BLDG F STE 380
KNOXVILLE TN
37920-1524
US

V. Phone/Fax

Practice location:
  • Phone: 865-544-9171
  • Fax: 865-305-6886
Mailing address:
  • Phone: 865-544-9171
  • Fax: 865-305-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2047
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: