MEDICARE: CONNOR PASSALACQUA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		OH
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207Q00000X	Family Medicine Physician	01099775A	IN
4	390200000X	Student in an Organized Health Care Education/Training Program		IN

General Provider Information

NPI Number	:	1598408262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNOR PASSALACQUA

Provider Business Mailing Address
First Line	:	966 BARTLEY ST
Second Line	:
City	:	JASPER
State	:	IN
Zip	:	47546-2641
Country	:	US
Telephone Number	:	812-996-7810
Fax Number	:	812-996-8465

Provider Business Practice Location Address
First Line	:	8423 MARKET ST STE 207
Second Line	:
City	:	BOARDMAN
State	:	OH
Zip	:	44512-6778
Country	:	US
Telephone Number	:	330-729-8700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2022
Last Update Date	:	06/04/2026

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Directions to “ CONNOR PASSALACQUA ” Practice Location

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