Provider Demographics
NPI:1578043063
Name:MCCONNON, ANTHONY MICHAEL
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:MCCONNON
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 1:500 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:BIG STONE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57216-8237
Mailing Address - Country:US
Mailing Address - Phone:605-541-1140
Mailing Address - Fax:605-541-0109
Practice Address - Street 1:2829 UNIVERSITY DR S STE 202
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6050
Practice Address - Country:US
Practice Address - Phone:701-478-7868
Practice Address - Fax:701-356-7005
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11351225100000X
ND2185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist