Provider Demographics
NPI:1316021793
Name:ROBINSON, CONNIE LEANNE (PA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:LEANNE
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:LEANNE
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:619 E MASON ST STE 4P57
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1034
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-525-2535
Practice Address - Street 1:619 E MASON ST
Practice Address - Street 2:SUITE 4P57
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1034
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002129363AM0700X
IL085.002129207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid
ILQ01479Medicare UPIN