Provider Demographics
NPI:1043803224
Name:CONNER, GEORGE JULIUS IV
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JULIUS
Last Name:CONNER
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ENCINO PL NE STE E1
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2645
Mailing Address - Country:US
Mailing Address - Phone:505-272-2573
Mailing Address - Fax:505-272-7751
Practice Address - Street 1:801 ENCINO PL NE STE E1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2645
Practice Address - Country:US
Practice Address - Phone:505-272-2573
Practice Address - Fax:505-272-7751
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program