Provider Demographics
NPI:1497841084
Name:CONNOLLY, PATRICK K
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:K
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 MEDICAL PKWY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1019
Mailing Address - Country:US
Mailing Address - Phone:512-454-0392
Mailing Address - Fax:512-454-1233
Practice Address - Street 1:3705 MEDICAL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1019
Practice Address - Country:US
Practice Address - Phone:512-452-0231
Practice Address - Fax:512-452-8083
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0262207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134909401Medicaid
TX804491OtherBCBS
TX804491Medicare PIN