Healthcare Provider Details

I. General information

NPI: 1679892434
Provider Name (Legal Business Name): CHRISTOPHER ROBERT O'CONNELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 MANUFACTURERS DR STE 110 54TH CIVIL SUPPORT TEAM
MADISON WI
53704-6207
US

IV. Provider business mailing address

6001 MANUFACTURERS DR STE 110
MADISON WI
53704-6207
US

V. Phone/Fax

Practice location:
  • Phone: 608-245-8441
  • Fax: 608-245-8498
Mailing address:
  • Phone: 608-245-8441
  • Fax: 608-245-8498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2525-023
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number2525-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: