Provider Demographics
NPI:1093984452
Name:O'CONNELL, DENNIS EUGENE (PA-C)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:EUGENE
Last Name:O'CONNELL
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 1:15 KNOLL LN
Mailing Address - Street 2:UNIT C
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2344
Mailing Address - Country:US
Mailing Address - Phone:415-686-2578
Mailing Address - Fax:
Practice Address - Street 1:250 BON AIR RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-925-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABR973ZMedicare PIN