Provider Demographics
NPI:1497055123
Name:CONNER, VIRGINIA E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:E
Last Name:CONNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:ELIZABETH
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 758952
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8952
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:4924 CAMPBELL BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-5908
Practice Address - Country:US
Practice Address - Phone:443-461-1997
Practice Address - Fax:443-461-1998
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04264363A00000X
PAOA002521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD362649YWV2Medicare PIN
MD362745YVZMedicare PIN
MD362745ZDDBMedicare PIN