Provider Demographics
NPI:1245210129
Name:CONNOR, BENJAMIN I (R-PA)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:I
Last Name:CONNOR
Suffix:
Gender:M
Credentials:R-PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 COURT ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-3295
Mailing Address - Country:US
Mailing Address - Phone:315-455-7610
Mailing Address - Fax:
Practice Address - Street 1:2700 COURT ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-3295
Practice Address - Country:US
Practice Address - Phone:315-455-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011039-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02729197Medicaid
NYQ44323Medicare UPIN
NYPA1445Medicare PIN
NYJ400038360Medicare PIN
NYJ400002488Medicare PIN