Basic Information
Provider Information | |||||||||
NPI: | 1568968634 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONNORS | ||||||||
FirstName: | TRISSA | ||||||||
MiddleName: | MCCLATCHEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCCLATCHEY | ||||||||
OtherFirstName: | TRISSA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 100 E LANCASTER AVE | ||||||||
Address2: |   | ||||||||
City: | WYNNEWOOD | ||||||||
State: | PA | ||||||||
PostalCode: | 190963450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4844762000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4603 FM 1463 RD STE 100 | ||||||||
Address2: |   | ||||||||
City: | KATY | ||||||||
State: | TX | ||||||||
PostalCode: | 774946846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2816120050 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2018 | ||||||||
LastUpdateDate: | 07/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | T6212 | TX | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.