Basic Information
| Provider Information | |||||||||
| NPI: | 1023681640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | LILLI | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| OtherLastName: | ALTENBURG | ||||||||
| OtherFirstName: | LILLI | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 46165 KAYAK CT UNIT A | ||||||||
| Address2: | |||||||||
| City: | GREAT MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206343083 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12070 OLD LINE CTR STE 303 | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016455100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2021 | ||||||||
| LastUpdateDate: | 10/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.