Healthcare Provider Details

I. General information

NPI: 1972554046
Provider Name (Legal Business Name): JAN STUART CONNELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W CATALDO
SPOKANE WA
99201-2217
US

IV. Provider business mailing address

217 W CATALDO
SPOKANE WA
99201-2217
US

V. Phone/Fax

Practice location:
  • Phone: 509-624-2326
  • Fax: 509-744-3040
Mailing address:
  • Phone: 509-624-2326
  • Fax: 509-744-3040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD000019284
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: