Provider Demographics
NPI:1558944249
Name:TRACEY, CONNOR SEAN
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:SEAN
Last Name:TRACEY
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 1:6 PATTON DR
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-4001
Mailing Address - Country:US
Mailing Address - Phone:203-247-3219
Mailing Address - Fax:
Practice Address - Street 1:3D RECON BAS UNIT 36180 FPO AP
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:96389-3618
Practice Address - Country:US
Practice Address - Phone:203-247-3219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman