Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 2018023704 | MO |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 2018023704 | MO |
NPI | 1083134902 |
---|---|
Provider Name | Dr. Trevor Conner |
First Address | Springfield, MO 65808-9007 |
Second Address | Springfield, MO 65807-7310 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2017 |
Last Update Date | 12/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200050337 | (05) | MO |