Provider Demographics
NPI:1497142160
Name:CONNER, JIMMY LARUE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:LARUE
Last Name:CONNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2903 DEER LEDGE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4554
Mailing Address - Country:US
Mailing Address - Phone:210-213-1817
Mailing Address - Fax:210-979-8274
Practice Address - Street 1:2903 DEER LEDGE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4554
Practice Address - Country:US
Practice Address - Phone:210-213-1817
Practice Address - Fax:210-979-8274
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00612363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical