MEDICARE: CONNOR PATRICK DOHERTY PA-C, ATC

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	2255A2300X	Athletic Trainer	096004117	IL
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1831735851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNOR PATRICK DOHERTY PA-C, ATC

Provider Business Mailing Address
First Line	:	3400 LAFAYETTE RD STE 200
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-1147
Country	:	US
Telephone Number	:	317-291-7422
Fax Number	:	317-291-7433

Provider Business Practice Location Address
First Line	:	5750 W 56TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-1695
Country	:	US
Telephone Number	:	317-291-7422
Fax Number	:	317-291-7433

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

Provider Enumeration Date	:	11/25/2019
Last Update Date	:	02/11/2026

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