Provider Demographics
NPI:1225284037
Name:CONNER, MATTHEW SHANE (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SHANE
Last Name:CONNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W 34TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1205
Mailing Address - Country:US
Mailing Address - Phone:512-452-8533
Mailing Address - Fax:
Practice Address - Street 1:720 W 34TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1205
Practice Address - Country:US
Practice Address - Phone:512-452-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7917207Q00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM7917OtherLICENSE