Provider Demographics
NPI:1083146161
Name:CONNOLLY, MEGAN T (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:T
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:T
Other - Last Name:ROWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:866-630-9882
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:2051 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1865
Practice Address - Country:US
Practice Address - Phone:815-741-4343
Practice Address - Fax:815-741-8660
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant