Provider Demographics
NPI:1033995774
Name:LABELLA, CONNOR JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:JAMES
Last Name:LABELLA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 NE COLUMBIA AVE APT 306E
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OR
Mailing Address - Zip Code:97818-9525
Mailing Address - Country:US
Mailing Address - Phone:941-586-2520
Mailing Address - Fax:
Practice Address - Street 1:450 TATONE ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OR
Practice Address - Zip Code:97818-8076
Practice Address - Country:US
Practice Address - Phone:541-481-7212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1212627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant