Provider Demographics
NPI:1164608147
Name:O'CONNOR, MATTHEW ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALAN
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N RACE ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3483
Mailing Address - Country:US
Mailing Address - Phone:270-651-4134
Mailing Address - Fax:270-651-4234
Practice Address - Street 1:1301 N RACE ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3483
Practice Address - Country:US
Practice Address - Phone:270-651-4134
Practice Address - Fax:270-651-4234
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45412367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100032700Medicaid