Provider Demographics
NPI:1265822126
Name:CONNER, WILLIAM BLAKE (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BLAKE
Last Name:CONNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1638 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3424
Mailing Address - Country:US
Mailing Address - Phone:910-615-6949
Mailing Address - Fax:910-615-9761
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-615-6949
Practice Address - Fax:910-615-9761
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-05430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant