Basic Information
| Provider Information | |||||||||
| NPI: | 1215238332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856530188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824111 | ||||||||
| FaxNumber: | 5208183630 | ||||||||
| Practice Location | |||||||||
| Address1: | 12635 W RUDASILL RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857439724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206823777 | ||||||||
| FaxNumber: | 5206822333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2010 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP3837 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 570762 | 05 | AZ | MEDICAID |