Provider Demographics
NPI:1144201351
Name:CONNORS, TERENCE VAUGHAN (PA)
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:VAUGHAN
Last Name:CONNORS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12909 SW PEMBROKE CIR N
Mailing Address - Street 2:
Mailing Address - City:LAKE SUZY
Mailing Address - State:FL
Mailing Address - Zip Code:34269-6937
Mailing Address - Country:US
Mailing Address - Phone:941-255-0770
Mailing Address - Fax:
Practice Address - Street 1:12909 SW PEMBROKE CIR N
Practice Address - Street 2:
Practice Address - City:LAKE SUZY
Practice Address - State:FL
Practice Address - Zip Code:34269-6937
Practice Address - Country:US
Practice Address - Phone:941-255-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02347859Medicaid
NYP00012841OtherRR MEDICARE
NYP00012841OtherRR MEDICARE
NY02347859Medicaid