Provider Demographics
NPI:1568645083
Name:CONNELL, MICHAEL CHARLES (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:CONNELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 WEST AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-6052
Mailing Address - Country:US
Mailing Address - Phone:518-583-0111
Mailing Address - Fax:518-583-2426
Practice Address - Street 1:3 IRONGATE CTR
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3471
Practice Address - Country:US
Practice Address - Phone:518-793-4409
Practice Address - Fax:518-615-0140
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002970OtherNYS LICENSE
NYMC1279404OtherDEA
NY002970OtherNYS LICENSE