Provider Demographics
NPI:1518243716
Name:O'CONNOR, BRETT D (FNP)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:D
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4480 HIGHWAY 101 STE G
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-8831
Mailing Address - Country:US
Mailing Address - Phone:541-997-1251
Mailing Address - Fax:
Practice Address - Street 1:4480 HIGHWAY 101 STE G
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-8831
Practice Address - Country:US
Practice Address - Phone:541-997-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP1110A363L00000X
OR202002300NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500777607Medicaid