Basic Information
| Provider Information | |||||||||
| NPI: | 1629605647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SODERQUIST | ||||||||
| FirstName: | CONNER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 BELMONT ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083341131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 279 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083346109 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2020 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.