Provider Demographics
NPI:1164866646
Name:CONNELLY, JOHN THOMAS III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:CONNELLY
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-936-7530
Mailing Address - Fax:803-936-7532
Practice Address - Street 1:146 E HOSPITAL DR STE 200
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4800
Practice Address - Country:US
Practice Address - Phone:803-936-7530
Practice Address - Fax:803-936-7532
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4532363AS0400X
FLPA9106938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical