Provider Demographics
NPI:1255861092
Name:O'CONNOR, BRIAN (MA, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913
Mailing Address - Country:US
Mailing Address - Phone:479-788-7651
Mailing Address - Fax:
Practice Address - Street 1:5210 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72913
Practice Address - Country:US
Practice Address - Phone:479-788-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer