Provider Demographics
NPI:1407984826
Name:O'CONNOR, EDITH (PA)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 BUCKS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:CA
Mailing Address - Zip Code:95971-9507
Mailing Address - Country:US
Mailing Address - Phone:530-283-7161
Mailing Address - Fax:530-283-7953
Practice Address - Street 1:1065 BUCKS LAKE RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95971-9507
Practice Address - Country:US
Practice Address - Phone:530-283-7161
Practice Address - Fax:530-283-7953
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant