Basic Information
| Provider Information | |||||||||
| NPI: | 1164084802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTIMER | ||||||||
| FirstName: | CONNOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2636 N MORELAND BLVD APT 21 | ||||||||
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| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441201466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199798592 | ||||||||
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| Practice Location | |||||||||
| Address1: | 730 W MARKET ST STE 2K | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965852 | ||||||||
| FaxNumber: | 4199965854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2019 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.006693RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.