Provider Demographics
NPI:1164866646
Name:CONNELLY, JOHN THOMAS III (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:CONNELLY
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:500 NORTHRIDGE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-3314
Mailing Address - Country:US
Mailing Address - Phone:803-736-3277
Mailing Address - Fax:
Practice Address - Street 1:145 PARK CENTRAL DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6469
Practice Address - Country:US
Practice Address - Phone:803-736-3277
Practice Address - Fax:803-408-8698
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9106938363A00000X
SC4532363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant