Provider Demographics
NPI:1730345117
Name:O'CONNOR, JEFFREY MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 WASHINGTON ST
Mailing Address - Street 2:STE 520
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2700
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 409
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-522-4158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003021326Medicaid
CTD400002689 - C00023Medicare PIN
CT003021326Medicaid