Provider Demographics
NPI:1508481706
Name:SUGRUE, CONNER DONALD (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNER
Middle Name:DONALD
Last Name:SUGRUE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 W 200 N
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-5009
Mailing Address - Country:US
Mailing Address - Phone:801-769-2571
Mailing Address - Fax:801-443-1164
Practice Address - Street 1:707 E MILL RD STE 303
Practice Address - Street 2:
Practice Address - City:VINEYARD
Practice Address - State:UT
Practice Address - Zip Code:84059-5730
Practice Address - Country:US
Practice Address - Phone:801-224-1300
Practice Address - Fax:801-225-3236
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT12462625-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program