Provider Demographics
NPI:1154813673
Name:LONGACRE, CONNOR ROMAN (PT,DPT)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:ROMAN
Last Name:LONGACRE
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 GOLDEN RIDGE RD STE 130
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-9541
Mailing Address - Country:US
Mailing Address - Phone:303-275-2190
Mailing Address - Fax:
Practice Address - Street 1:660 GOLDEN RIDGE RD STE 130
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401
Practice Address - Country:US
Practice Address - Phone:303-275-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL0015663225100000X, 2251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic