Basic Information
| Provider Information | |||||||||
| NPI: | 1497055123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSO | ||||||||
| OtherFirstName: | VIRGINIA | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 758952 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212758952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049685700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4924 CAMPBELL BLVD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212365908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434611997 | ||||||||
| FaxNumber: | 4434611998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2010 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C04264 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.