Provider Demographics
NPI:1174827893
Name:CONNOR, KIMBERLY ELAINE (PA-C, CLE)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ELAINE
Last Name:CONNOR
Suffix:
Gender:F
Credentials:PA-C, CLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1247 SUNCREST TOWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1876
Mailing Address - Country:US
Mailing Address - Phone:304-599-8000
Mailing Address - Fax:304-599-8003
Practice Address - Street 1:110 SIMS CIRCLE
Practice Address - Street 2:
Practice Address - City:TRIADELPHIA
Practice Address - State:WV
Practice Address - Zip Code:26059-1154
Practice Address - Country:US
Practice Address - Phone:304-599-8000
Practice Address - Fax:304-599-8003
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-41918174N00000X
WV349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1174827893Medicaid
OH018811Medicaid